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PIP payment, claims within this remittance advice covered by that payment would be offset using this code to remove the claim payment from the current check. The sign of the amount in PLB04 determines whether this is a payment (negative) or reduction (positive). This payment and recoupment is effectively a loan to the provider and loan repayment. See section 1.10.2.5, Advance Payments and Reconciliation, for additional information. PL Payment Final This is the final settlement. RA Retro-activity Adjustment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. RE Return on Equity SL Student Loan Repayment TL Third Party Liability This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. WO Overpayment Recovery This is the recovery of previous overpayment. An identifying number must be provided in PLB03-2. See the notes on codes 72 and B3 for additional information about balancing against a provider refund. WU Unspecified Recovery Medicare is currently using this code to represent penalty collections withheld for the IRS (an outside source). C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Use when necessary to assist the receiver in identifying, tracking or reconcilling the adjustment. See sections 1.10.2.10 (Capitation and Related Payments), 1.10.2.5 (Advanced Payments and Reconciliation) and 1.10.2.12 (Balance Forward Processing) for further information. PLB-04 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount PLB04 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. PLB-05 C042 Adjustment Identifier Max use 1 Optional 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 107 127 To provide the category and identifying reference information for an adjustment - PLB05 is the adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-06 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB06 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-07 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB07 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-08 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB08 is the adjustment amount. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 108 127 Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-09 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB09 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-10 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB10 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-11 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB11 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 109 127 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-12 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB12 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-13 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB13 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_27 |
the category and identifying reference information for an adjustment - PLB13 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-14 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB14 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 110 127 Summary end SE 0200 Summary SE Transaction Set Trailer To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments) Example SE 000000 0001 Max use 1 Required SE-01 96 Transaction Segment Count Min 1 Max 10 Numeric (N0) Required Total number of segments included in a transaction set including ST and SE segments SE-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Numbers in ST02 and SE02 must be identical. The originator assigns the Transaction Set Control Number, which must be unique within a functional group (GS-GE). This unique number also aids in error resolution research. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 111 127 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE 000 000 Max use 1 Required GE-01 97 Number of Transaction Sets Included Min 1 Max 6 Numeric (N0) Required Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element GE-02 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 112 127 IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA 00 000000000 Max use 1 Required IEA-01 I16 Number of Included Functional Groups Min 1 Max 5 Numeric (N0) Required A count of the number of functional groups included in an interchange IEA-02 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 113 127 EDI Samples Example 1: Dollars and Data Sent Separately ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 012345678 X 005010X221A1 ST 835 112233 BPR I 1100 C ACH CCP 01 888999777 DA 24681012 1935665544 01 111333555 DA 144444 20190316 TRN 1 71700666555 1935665544 DTM 405 20190314 N1 PR RUSHMORE LIFE N3 10 SOUTH AVENUET N4 RAPID CITY SD 55111 PER BL JOHN WAYNE TE 8005551212 EX 123 N1 PE ACME MEDICAL CENTER XX 5544667733 REF 0B 777667755 LX 1 CLP 5554555444 1 800 500 300 12 94060555410000 11 1 NM1 QC 1 BUDD WILLIAM MI 33344555510 AMT AU 800 SVC HC 99211 800 500 DTM 472 20190301 CAS PR 1 300 AMT B6 800 CLP 8765432112 1 1200 600 600 12 9407779923000 11 1 NM1 QC 1 SETTLE SUSAN MI 44455666610 AMT AU 1200 SVC HC 93555 1200 600 DTM 472 20190310 CAS PR 1 600 AMT B6 1200 SE 26 112233 GE 1 012345678 IEA 1 191511902 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 114 127 Example 2: Multiple Claims Single Check ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 35681 BPR I 810.8 C CHK 20190331 TRN 1 12345 1512345678 REF EV XYZ CLEARINGHOUSE N1 PR DENTAL OF ABC N3 225 MAIN STREET N4 CENTERVILLE PA 17111 PER BL JANE DOE TE 9005555555 N1 PE BAN DDS LLC XX 9999947036 REF 0B 212121212 LX 1 CLP 7722337 1 226 132 12 119932404007801 11 1 NM1 QC 1 DOE SANDY MI SJD11112 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190324 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 119 74 12 119932404007801 11 1 NM1 QC 1 DOE SALLY MI SJD11111 NM1 IL 1 DOE JOHN MI SJD11111 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 74 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 226 108 24 12 119932404007801 11 1 NM1 QC 1 SMITH SALLY MI SJD11113 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 1 29 25, 8:52 | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_28 |
CAS CO 45 24 AMT B6 49 CLP 7722337 1 226 108 24 12 119932404007801 11 1 NM1 QC 1 SMITH SALLY MI SJD11113 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 115 127 AMT B6 25 SVC AD D0220 25 0 DTM 472 20190324 CAS PR 3 14 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 0 DTM 472 20190324 CAS PR 3 10 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 1145 14 902 12 119932404007801 11 1 NM1 QC 1 SMITH SAM MI SJD11116 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 14 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 45 11 AMT B6 14 SVC AD D2790 940 0 DTM 472 20190324 CAS PR 3 756 CAS CO 45 184 SVC AD D2950 180 0 DTM 472 20190324 CAS PR 3 146 CAS CO 45 34 CLP 7722337 1 348 16.8 44.2 12 119932404007801 11 1 NM1 QC 1 JONES SAM MI SJD11122 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 28 SVC AD D4342 125 0 DTM 472 20190313 CAS CO 45 125 SVC AD D4381 43 0 DTM 472 20190313 CAS PR 3 33 CAS CO 45 10 SVC AD D2950 180 16.8 DTM 472 20190313 CAS PR 3 11.2 CAS CO 45 152 AMT B6 28 CLP 7722337 1 226 132 12 119932404007801 11 1 NM1 QC 1 JONES SALLY MI SJD11133 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190321 CAS CO 45 21 AMT B6 25 SVC AD D0220 25 14 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 116 127 DTM 472 20190321 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190321 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190321 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190321 CAS CO 45 24 AMT B6 49 CLP 7722337 1 179 108 12 119932404007801 11 1 NM1 QC 1 DOE SAM MI SJD99999 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 108 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 129 82 12 119932404007801 11 1 NM1 QC 1 DOE SUE MI SJD88888 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 82 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D1120 54 37 DTM 472 20190324 CAS CO 45 17 AMT B6 37 SVC AD D1208 29 20 DTM 472 20190324 CAS CO 45 9 AMT B6 20 CLP 7722337 1 221 144 12 119932404007801 11 1 NM1 QC 1 DOE DONNA MI SJD77777 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 144 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0330 92 62 DTM 472 20190324 CAS CO 45 30 AMT B6 62 SVC AD D1120 54 37 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 117 127 DTM 472 20190324 CAS CO 45 17 AMT B6 37 SVC AD D1208 29 20 DTM 472 20190324 CAS CO 45 9 AMT B6 20 SE 183 35681 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 118 127 Example 3: Claim Specific Negotiated Discount ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 35681 BPR I 132 C CHK 20190331 TRN 1 12345 1512345678 REF EV CLEARINGHOUSE N1 PR DELTA DENTAL OF ABC N3 225 MAIN STREET N4 CENTERVILLE PA 17111 PER BL JANE DOE TE 9005555555 N1 PE BAN DDS LLC XV 999994703 LX 1 CLP 7722337 1 226 132 12 119932404007801 NM1 QC 1 DOE SALLY MI SJD11111 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 131 21 AMT B6 25 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 131 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190324 CAS CO 131 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 131 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 131 24 AMT B6 49 SE 35 35681 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 119 127 Example 4: Claim Adjustment Reason Code 45 ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 80.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF 0B 123456789 LX 1 CLP PATACCT 1 400 80 MC | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_29 |
N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF 0B 123456789 LX 1 CLP PATACCT 1 400 80 MC CLAIMNUMBER 11 1 NM1 QC 1 DOE JOHN N MI ABC123456789 REF 1L 12345F DTM 050 20190209 PER CX G CUSTOMER SERVICE DEPARTMENT TE 8004074627 AMT AU 150 SVC HC 99213 150 80 1 DTM 472 20190101 CAS CO 45 70 AMT B6 80 SVC HC 85003 100 0 1 DTM 472 20190101 CAS CO 204 100 SVC HC 36415 150 0 1 DTM 472 20190101 CAS CO 97 150 SE 33 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 120 127 Example 5a: Line Service Tax impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 11.06 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF 0B 123456789 LX 1 CLP PCN 1 36.20 11.06 12 CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 MOA N25 REF 1L 102345 REF EA 065789 DTM 050 20170113 AMT AU 36.20 SVC HC 99214 26.2 3.06 DTM 472 20170109 CAS CO 45 23.2 137 -.06 REF 6R B1 AMT B6 3 SVC HC 36415 10 8 DTM 472 20170109 CAS CO 45 2 REF 6R B2 AMT B6 8 SE 35 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 121 127 Example 5b: Line Service Bonuses impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 12.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF 0B 123456789 LX 1 CLP PCN 1 25 12 10 12 CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 MOA N25 REF 1L 102345 REF EA 065789 DTM 050 20170113 AMT AU 25 SVC HC 99214 25 12 DTM 472 20170109 CAS CO 45 5 161 -2 CAS PR 3 10 REF 6R 123 AMT B6 20 SE 31 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 122 127 Example 5c: Line Service Penalty impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 8.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF 0B 123456789 LX 1 CLP PCN 1 25 8 10 12 CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 MOA N25 REF 1L 102345 REF EA 065789 DTM 050 20170113 AMT AU 25 SVC HC 99214 25 8 DTM 472 20170109 CAS CO 45 5 B4 2 CAS PR 3 10 REF 6R 123 AMT B6 20 SE 31 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 123 127 Example 6: Not Covered Not Authorized Inpatient Facility claim days ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 8000.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF 0B 123456789 LX 1 CLP PATACCT 1 40000 8000 MC CLAIMNUMBER 11 1 CAS CO 197 2000 1 45 30000 NM1 QC 1 DOE JOHN N MI ABC123456789 REF 1L 12345F DTM 232 20190101 DTM 233 20190105 DTM 050 20190209 PER CX G CUSTOMER SERVICE DEPARTMENT TE 8004001212 AMT AU 38000 QTY CA 4 SE 27 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 124 127 Example 8a: Claim submitted with incorrect subscriber as patient and incorrect ID ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 120.03 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_30 |
HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 120.03 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF 0B 123456789 LX 1 CLP 04777796TLC777122 1 155 120.03 13 8838888212 11 1 NM1 QC 1 MASTERS MARVIN L MI 80444444403 NM1 IL 1 CABLE MABEL MI 80444444403 NM1 74 1 MASTERS MARVIN C 80444444401 NM1 82 1 SHELTON MD BLAKE XX 1666666666 REF 1L 28 REF CE HSOAP-LAOA DTM 232 20191114 DTM 233 20181114 DTM 050 20181119 AMT AU 155 SVC HC 99393 155 120.03 1 DTM 472 20181114 CAS CO 45 34.97 REF LU 11 REF 6R 22261822 AMT B6 120.03 SE 34 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 125 127 Example 8b: Claim submitted with incorrect subscriber name and ID ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 35.06 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF 0B 123456789 LX 1 CLP 02333TLC222222 1 115 35.06 35 13 8333333214 11 1 NM1 QC 1 KEATON ALEX P MI 80000006006 NM1 IL 1 THOMAS JASON MI 80000006006 NM1 74 1 JEROME C 80000006001 NM1 82 1 BLOOD MD RED N XX 1888888886 REF 1L 28 REF CE OAPOS-LAOA DTM 232 20191113 DTM 233 20191113 DTM 050 20191119 AMT AU 115 SVC HC 99213 115 35.06 1 DTM 472 20191113 CAS CO 45 44.94 CAS PR 3 35 REF LU 11 REF 6R 22261389 AMT B6 70.06 SE 35 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 126 127 Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including X12, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation. Example 8c: Claim submitted with for subscriber missing the Middle initial ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 2415.25 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF 0B 123456789 LX 1 CLP 05444444TLC999999 1 3903 2415.25 13 8777777782 21 1 NM1 QC 1 GONZALES SAMMY MI 80455555502 NM1 IL 1 LAPLANTE FERN MI 80455555502 NM1 74 1 R NM1 82 1 GOOD MD ROBERT B XX 19999999987 REF 1L 28 REF CE OAPOS-LAOA DTM 232 20191101 DTM 233 20191101 DTM 050 20191114 AMT AU 3903 AMT F5 150 SVC HC 59400 3903 2415.25 1 DTM 472 20191101 CAS CO 45 1487.75 REF LU 21 REF 6R 22215592 AMT B6 2415.25 SE 35 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 127 127 | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_31 |
Stedi maintains this guide based on public documentation from X12 HIPAA. Contact X12 HIPAA for official EDI specifications. To report any errors in this guide, please contact us. X12 835 Health Care Claim Payment Advice (X221A1) X12 Release 5010 Revised May 3, 2024 Go to Stedi Network This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Payment Advice Transaction Set (835) for use within the context of the Electronic Data Interchange (EDI) environment. This transaction set can be used to make a payment, send an Explanation of Benefits (EOB) remittance advice, or make a payment and send an EOB remittance advice only from a health insurer to a health care provider either directly or via a financial institution. Delimiters Segment Element Component Repetition View the latest version of this implementation guide as an interactive webpage https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice- x221a1 01GRYB6DS30MGXWBPFZCM3695E POWERED BY Build EDI implementation guides at stedi.com 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 1 128 Overview ISA - Interchange Control Header Max use 1 Required GS - Functional Group Header Max use 1 Required Heading ST 0100 Transaction Set Header Max use 1 Required BPR 0200 Financial Information Max use 1 Required TRN 0400 Reassociation Trace Number Max use 1 Required CUR 0500 Foreign Currency Information Max use 1 Optional REF 0600 Receiver Identification Max use 1 Optional REF 0600 Version Identification Max use 1 Optional DTM 0700 Production Date Max use 1 Optional Payer Identification Loop N1 0800 Payer Identification Max use 1 Required N3 1000 Payer Address Max use 1 Required N4 1100 Payer City, State, ZIP Code Max use 1 Required REF 1200 Additional Payer Identification Max use 4 Optional PER 1300 Payer Business Contact Information Max use 1 Optional PER 1300 Payer Technical Contact Information Max use 1 Required PER 1300 Payer WEB Site Max use 1 Optional Payee Identification Loop N1 0800 Payee Identification Max use 1 Required N3 1000 Payee Address Max use 1 Optional N4 1100 Payee City, State, ZIP Code Max use 1 Optional REF 1200 Payee Additional Identification Max use 1 Optional RDM 1400 Remittance Delivery Method Max use 1 Optional Detail Header Number Loop LX 0030 Header Number Max use 1 Required TS3 0050 Provider Summary Information Max use 1 Optional TS2 0070 Provider Supplemental Summary Information Max use 1 Optional 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 2 128 Claim Payment Information Loop CLP 0100 Claim Payment Information Max use 1 Required CAS 0200 Claim Adjustment Max use 99 Optional NM1 0300 Patient Name Max use 1 Required NM1 0300 Insured Name Max use 1 Optional NM1 0300 Corrected Patient Insured Name Max use 1 Optional NM1 0300 Service Provider Name Max use 1 Optional NM1 0300 Crossover Carrier Name Max use 1 Optional NM1 0300 Corrected Priority Payer Name Max use 1 Optional NM1 0300 Other Subscriber Name Max use 1 Optional MIA 0330 Inpatient Adjudication Information Max use 1 Optional MOA 0350 Outpatient Adjudication Information Max use 1 Optional REF 0400 Other Claim Related Identification Max use 5 Optional REF 0400 Rendering Provider Identification Max use 10 Optional DTM 0500 Statement From or To Date Max use 2 Optional DTM 0500 Coverage Expiration Date Max use 1 Optional DTM 0500 Claim Received Date Max use 1 Optional PER 0600 Claim Contact Information Max use 2 Optional AMT 0620 Claim Supplemental Information Max use 13 Optional QTY 0640 Claim Supplemental Information Quantity Max use 14 Optional Service Payment Information Loop SVC 0700 Service Payment Information Max use 1 Required DTM 0800 Service Date Max use 2 Optional CAS 0900 Service Adjustment Max use 99 Optional REF 1000 Service Identification Max use 8 Optional REF 1000 Line Item Control Number Max use 1 Optional REF 1000 Rendering Provider Information Max use 10 Optional REF 1000 HealthCare Policy Identification Max use 5 Optional AMT 1100 Service Supplemental Amount Max use 9 Optional QTY 1200 Service Supplemental Quantity Max use 6 Optional LQ 1300 Health Care Remark Codes Max use 99 Optional 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 3 128 Summary PLB 0100 Provider Adjustment Max use 1 Optional SE 0200 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 4 128 ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange- related control segments Example ISA 00 00 XX XXXXXXXXXXXXXX X XX XXXXXXXXXXXXXXX 250130 0532 00501 00000000 0 X X Max use 1 Required ISA-01 I01 Authorization Information Qualifier Identifier (ID) Required Code identifying the type of information in the Authorization Information 00 No Authorization Information Present (No Meaningful Information in I02) ISA-02 I02 Authorization Information Min 10 Max 10 String (AN) Required Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01) ISA-03 I03 Security Information Qualifier Identifier (ID) Required Code identifying the type of information in the Security Information 00 No Security Information Present (No Meaningful Information in I04) ISA-04 I04 Security Information Min 10 Max 10 String (AN) Required This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03) ISA-05 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-06 I06 Interchange Sender ID Min 15 Max 15 | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_0 |
information is set by the Security Information Qualifier (I03) ISA-05 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-06 I06 Interchange Sender ID Min 15 Max 15 String (AN) Required Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element ISA-07 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 5 128 Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-08 I07 Interchange Receiver ID Min 15 Max 15 String (AN) Required Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them ISA-09 I08 Interchange Date YYMMDD format Date (DT) Required Date of the interchange ISA-10 I09 Interchange Time HHMM format Time (TM) Required Time of the interchange ISA-11 I65 Repetition Separator Min 1 Max 1 String (AN) Required Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator Repetition Separator ISA-12 I11 Interchange Control Version Number Identifier (ID) Required Code specifying the version number of the interchange control segments 00501 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003 ISA-13 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender ISA-14 I13 Acknowledgment Requested Min 1 Max 1 Identifier (ID) Required Code indicating sender's request for an interchange acknowledgment 0 No Interchange Acknowledgment Requested 1 Interchange Acknowledgment Requested (TA1) ISA-15 I14 Interchange Usage Indicator Min 1 Max 1 Identifier (ID) Required Code indicating whether data enclosed by this interchange envelope is test, production or information I Information 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 6 128 P Production Data T Test Data ISA-16 I15 Component Element Separator Min 1 Max 1 String (AN) Required Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator Component Element Separator 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 7 128 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GS HP XXXXXXX XXXXXX 20250130 0836 00000 X 005010 X221A1 Max use 1 Required GS-01 479 Functional Identifier Code Identifier (ID) Required Code identifying a group of application related transaction sets HP Health Care Claim Payment Advice (835) GS-02 142 Application Sender's Code Min 2 Max 15 String (AN) Required Code identifying party sending transmission; codes agreed to by trading partners GS-03 124 Application Receiver's Code Min 2 Max 15 String (AN) Required Code identifying party receiving transmission; codes agreed to by trading partners GS-04 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year GS-05 337 Time HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time (TM) Required Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H hours (00-23), M minutes (00-59), S integer seconds (00-59) and DD decimal seconds; decimal seconds are expressed as follows: D tenths (0-9) and DD hundredths (00-99) GS-06 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480 T Transportation Data Coordinating Committee (TDCC) X Accredited Standards Committee X12 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 8 128 GS-08 480 Version Release Industry Identifier Code String (AN) Required Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed 005010X221A1 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 9 128 Heading ST 0100 Heading ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST 835 0001 Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) Required Code uniquely identifying a Transaction Set The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set). Usage notes The only valid value within this transaction set for ST01 is 835. 835 Health Care Claim Payment Advice ST-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_1 |
selects the Invoice Transaction Set). Usage notes The only valid value within this transaction set for ST01 is 835. 835 Health Care Claim Payment Advice ST-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Start with a number, for example 0001, and increment from there. This number must be unique within a specific group and interchange, but it can be repeated in other groups and interchanges. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 10 128 BPR 0200 Heading BPR Financial Information To indicate the beginning of a Payment Order Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and or information from payer to payee to occur Usage notes Use the BPR to address a single payment to a single payee. A payee may represent a single provider, a provider group, or multiple providers in a chain. The BPR contains mandatory information, even when it is not being used to move funds electronically. Example BPR U 000000 C NON CCP 04 XXXXXXXX DA XXXXXX XXXX XXXXXX XXXXXXXXX 01 XXXXXXX DA X 20250130 If either Depository Financial Institution (DFI) Identification Number Qualifier (BPR-06) or Sender DFI Identifier (BPR-07) is present, then the other is required If Account Number Qualifier (BPR-08) is present, then Sender Bank Account Number (BPR-09) is required If either Depository Financial Institution (DFI) Identification Number Qualifier (BPR-12) or Receiver or Provider Bank ID Number (BPR-13) is present, then the other is required If Account Number Qualifier (BPR-14) is present, then Receiver or Provider Account Number (BPR-15) is required Max use 1 Required BPR-01 305 Transaction Handling Code Identifier (ID) Required Code designating the action to be taken by all parties C Payment Accompanies Remittance Advice Use this code to instruct your third party processor to move both funds and remittance detail together through the banking system. D Make Payment Only Use this code to instruct your third party processor to move only funds through the banking system and to ignore any remittance information. H Notification Only Use this code when the actual provider payment (BPR02) is zero and the transaction is not being used for Prenotification of Future Transfers. This indicates remittance information without any associated payment. I Remittance Information Only Use this code to indicate to the payee that the remittance detail is moving separately from the payment. P Prenotification of Future Transfers This code is used only by the payer and the banking system to initially validate account numbers before beginning an EFT relationship. Contact your VAB for additional information. U Split Payment and Remittance Use this code to instruct the third party processor to split the payment and remittance detail, and send each on a separate path. X Handling Party's Option to Split Payment and Remittance Use this code to instruct the third party processor to move the payment and remittance detail, either together or separately, based upon end point requests or capabilities. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 11 128 BPR-02 782 Total Actual Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount BPR02 specifies the payment amount. Usage notes Use BPR02 for the total payment amount for this 835. The total payment amount for this 835 cannot exceed eleven characters, including decimals (99999999.99). Although the value can be zero, the 835 cannot be issued for less than zero dollars. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). BPR-03 478 Credit or Debit Flag Code Identifier (ID) Required Code indicating whether amount is a credit or debit C Credit Use this code to indicate a credit to the provider's account and a debit to the payer's account, initiated by the payer. In the case of an EFT, no additional action is required of the provider. Also use this code when a check is issued for the payment. D Debit Use this code to indicate a debit to the payer's account and a credit to the provider's account, initiated by the provider at the instruction of the payer. Extreme caution must be used when using Debit transactions. Contact your VAB for information about debit transactions. The rest of this segment and document assumes that a credit payment is being used. BPR-04 591 Payment Method Code Identifier (ID) Required Code identifying the method for the movement of payment instructions ACH Automated Clearing House (ACH) Use this code to move money electronically through the ACH, or to notify the provider that an ACH transfer was requested. When this code is used, see BPR05 through BPR15 for additional requirements. BOP Financial Institution Option Use this code to indicate that the third party processor will choose the method of payment based upon end point requests or capabilities. When this code is used, see BPR05 through BPR15 for additional requirements. CHK Check Use this code to indicate that a check has been issued for payment. FWT Federal Reserve Funds Wire Transfer - Nonrepetitive Use this code to indicate that the funds were sent through the wire system. When this code is used, see BPR05 through BPR15 for additional requirements. NON Non-Payment Data Use this code when the Transaction Handling Code (BPR01) is H, indicating that this is information only and no dollars are to be moved. BPR-05 812 Payment Format Code Identifier (ID) Optional Code identifying the payment format to be used CCP Cash Concentration Disbursement plus Addenda (CCD ) (ACH) 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 12 | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_2 |
Payment Format Code Identifier (ID) Optional Code identifying the payment format to be used CCP Cash Concentration Disbursement plus Addenda (CCD ) (ACH) 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 12 128 Use the CCD format to move money and up to 80 characters of data, enough to reassociate dollars and data when the dollars are sent through the ACH and the data is sent on a separate path. The addenda must contain a copy of the TRN segment. CTX Corporate Trade Exchange (CTX) (ACH) Use the CTX format to move dollars and data through the ACH. The CTX format can contain up to 9,999 addenda records of 80 characters each. The CTX encapsulates the complete 835 and all envelope segments. BPR-06 506 Depository Financial Institution (DFI) Identification Number Qualifier Optional Identifier (ID) Code identifying the type of identification number of Depository Financial Institution (DFI) When using this transaction set to initiate a payment, all or some of BPR06 through BPR16 may be required, depending on the conventions of the specific financial channel being used. BPR06 and BPR07 relate to the originating depository financial institution (ODFI). Usage notes BPR06 through BPR09 relate to the originating financial institution and the originator's account (payer). 01 ABA Transit Routing Number Including Check Digits (9 digits) The ABA transit routing number is a unique number identifying every bank in the United States. 04 Canadian Bank Branch and Institution Number BPR-07 507 Sender DFI Identifier Min 3 Max 12 String (AN) Optional Depository Financial Institution (DFI) identification number Usage notes Use this number for the identifying number of the financial institution sending the transaction into the applicable network. BPR-08 569 Account Number Qualifier Identifier (ID) Optional Code indicating the type of account BPR08 is a code identifying the type of bank account or other financial asset. Usage notes Use this code to identify the type of account in BPR09. DA Demand Deposit BPR-09 508 Sender Bank Account Number Min 1 Max 35 String (AN) Optional Account number assigned BPR09 is the account of the company originating the payment. This account may be debited or credited depending on the type of payment order. Usage notes 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 13 128 Use this number for the originator's account number at the financial institution. BPR-10 509 Payer Identifier Min 10 Max 10 String (AN) Optional A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification. BPR10 shall be mutually established between the originating depository financial institution (ODFI) and the company originating the payment. BPR-11 510 Originating Company Supplemental Code Min 9 Max 9 String (AN) Optional A code defined between the originating company and the originating depository financial institution (ODFI) that uniquely identifies the company initiating the transfer instructions Usage notes Use this code to further identify the payer by division or region. The element must be left justified and space filled to meet the minimum element size requirements. If used, this code must be identical to TRN04, excluding trailing spaces. BPR-12 506 Depository Financial Institution (DFI) Identification Number Qualifier Optional Identifier (ID) Code identifying the type of identification number of Depository Financial Institution (DFI) BPR12 and BPR13 relate to the receiving depository financial institution (RDFI). Usage notes BPR12 through BPR15 relate to the receiving financial institution and the receiver's account. 01 ABA Transit Routing Number Including Check Digits (9 digits) The ABA transit routing number is a unique number identifying every bank in the United States. 04 Canadian Bank Branch and Institution Number BPR-13 507 Receiver or Provider Bank ID Number Min 3 Max 12 String (AN) Optional Depository Financial Institution (DFI) identification number Usage notes Use this number for the identifying number of the financial institution receiving the transaction from the applicable network. BPR-14 569 Account Number Qualifier Identifier (ID) Optional Code indicating the type of account BPR14 is a code identifying the type of bank account or other financial asset. Usage notes Use this code to identify the type of account in BPR15. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 14 128 DA Demand Deposit SG Savings BPR-15 508 Receiver or Provider Account Number Min 1 Max 35 String (AN) Optional Account number assigned BPR15 is the account number of the receiving company to be debited or credited with the payment order. Usage notes Use this number for the receiver's account number at the financial institution. BPR-16 373 Check Issue or EFT Effective Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year BPR16 is the date the originating company intends for the transaction to be settled (i.e., Payment Effective Date). Usage notes Use this for the effective entry date. If BPR04 is ACH, this is the date that the money moves from the payer and is available to the payee. If BPR04 is CHK, this is the check issuance date. If BPR04 is FWT, this is the date that the payer anticipates the money to move. As long as the effective date is a business day, this is the settlement date. If BPR04 is NON', enter the date of the 835. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 15 128 TRN 0400 Heading TRN Reassociation Trace Number To uniquely identify a transaction to an application Usage notes This segment's purpose is to uniquely identify this transaction set and to aid in reassociating payments and remittances that have been separated. Example TRN 1 X XXXXXXXXXX XXXX Max use 1 Required TRN-01 481 Trace Type Code Identifier (ID) Required Code identifying which transaction is being referenced 1 Current Transaction Trace Numbers TRN-02 127 Check or EFT Trace Number Min 1 Max | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_3 |
aid in reassociating payments and remittances that have been separated. Example TRN 1 X XXXXXXXXXX XXXX Max use 1 Required TRN-01 481 Trace Type Code Identifier (ID) Required Code identifying which transaction is being referenced 1 Current Transaction Trace Numbers TRN-02 127 Check or EFT Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TRN02 provides unique identification for the transaction. Usage notes This number must be unique within the sender receiver relationship. The number is assigned by the sender. If payment is made by check, this must be the check number. If payment is made by EFT, this must be the EFT reference number. If this is a non- payment 835, this must be a unique remittance advice identification number. See 1.10.2.3, Reassociation of Dollars and Data, for additional information. TRN-03 509 Payer Identifier Min 10 Max 10 String (AN) Required A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification. TRN03 identifies an organization. Usage notes This must be a 1 followed by the payer's EIN (or TIN). TRN-04 127 Originating Company Supplemental Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TRN04 identifies a further subdivision within the organization. Usage notes 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 16 128 If both TRN04 and BPR11 are used, they must be identical, excluding trailing spaces. Since BPR11 has a min max value of 9 9, whenever both are used, this element is restricted to a maximum size of 9. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 17 128 CUR 0500 Heading CUR Foreign Currency Information To specify the currency (dollars, pounds, francs, etc.) used in a transaction Usage notes When the CUR segment is not present, the currency of payment is defined as US dollars. Required when the payment is not being made in US dollars. If not required by this implementation guide, do not send. Example CUR PR XXX Max use 1 Optional CUR-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer CUR-02 100 Currency Code Min 3 Max 3 Identifier (ID) Required Code (Standard ISO) for country in whose currency the charges are specified Usage notes This is the currency code for the payment currency. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 18 128 REF 0600 Heading REF Receiver Identification To specify identifying information Usage notes This is the business identification information for the transaction receiver. This may be different than the EDI address or identifier of the receiver. This is the initial receiver of the transaction. This information must not be updated if the transaction is routed through multiple intermediaries, such as clearinghouses, before reaching the payee. Required when the receiver of the transaction is other than the payee (e.g., a clearinghouse or billing service). If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example REF EV X Variants (all may be used) REF Version Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EV Receiver Identification Number REF-02 127 Receiver Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 19 128 REF 0600 Heading REF Version Identification To specify identifying information Usage notes Update this reference number whenever a change in the version or release number affects the 835. (This is not the ANSI ASCX12 version number as reported in the GS segment.) Required when necessary to report the version number of the adjudication system that generated the claim payments in order for the payer to resolve customer service questions from the payee. If not required by this implementation guide, do not send. Example REF F2 XXXXXX Variants (all may be used) REF Receiver Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F2 Version Code - Local REF-02 127 Version Identification Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 20 128 DTM 0700 Heading DTM Production Date To specify pertinent dates and times Usage notes If your adjudication cycle completed on Thursday and your 835 is produced on Saturday, you are required to populate this segment with Thursday's date. Required when the cut off date of the adjudication system remittance run is different from the date of the 835 as identified in the related GS04 element. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example DTM 405 20250130 Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 405 Production DTM-02 373 Production Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes Report the end date for the adjudication production cycle for claims included in this 835. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_4 |
represents the first two digits of the calendar year Usage notes Report the end date for the adjudication production cycle for claims included in this 835. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 21 128 1000A Payer Identification Loop Max 1 Required Variants (all may be used) Payee Identification Loop N1 0800 Heading Payer Identification Loop N1 Payer Identification To identify a party by type of organization, name, and code Usage notes Use this N1 loop to provide the name address information for the payer. The payer's secondary identifying reference number is provided in N104, if necessary. Example N1 PR X XV XX If either Identification Code Qualifier (N1-03) or Payer Identifier (N1-04) is present, then the other is required Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer N1-02 93 Payer Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). N1-04 67 Payer Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 22 128 N3 1000 Heading Payer Identification Loop N3 Payer Address To specify the location of the named party Example N3 X XXX Max use 1 Required N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 23 128 N4 1100 Heading Payer Identification Loop N4 Payer City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXX XX XXXX XXX Only one of Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Payer State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 24 128 REF 1200 Heading Payer Identification Loop REF Additional Payer Identification To specify identifying information Usage notes The ID available in the TRN and N1 segments must be used before using the REF segment. Required when additional payer identification numbers beyond those in the TRN and Payer N1 segments are needed. If not required by this implementation guide, may be sent at sender's discretion, but cannot be required by the receiver. Example REF 2U XXXX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number For Medicare carriers or intermediaries, use this qualifier for the Medicare carrier or intermediary ID number. For Blue Cross and Blue Shield Plans, use this qualifier for the Blue Cross Blue Shield association plan code. EO Submitter Identification Number This is required when the original transaction sender is not the payer or is identified by an identifier other than those already provided. This is not updated by third parties between the payer and the payee. An example of a use for this qualifier is when identifying a clearinghouse that created the 835 when the health plan sent a proprietary format to the clearinghouse. HI Health Industry Number (HIN) NF National Association of Insurance Commissioners (NAIC) Code This is the preferred value when identifying the payer. REF-02 127 Additional Payer Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 25 128 PER 1300 Heading Payer Identification Loop PER Payer Business Contact Information To identify a person or office to whom administrative communications should be directed Usage notes When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800) 555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number. Required when there is a | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_5 |
area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800) 555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number. Required when there is a business contact area that would apply to this remittance and all the claims. If not required by this implementation guide, do not send. Example PER CX XXXXX EM XXX EX XXXXX EX XXXX Variants (all may be used) PER Payer Technical Contact Information PER Payer WEB Site If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required If either Communication Number Qualifier (PER-05) or Payer Contact Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Payer Contact Name Min 1 Max 60 String (AN) Optional Free-form name Usage notes Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). PER-03 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 26 128 PER-04 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 27 128 PER 1300 Heading Payer Identification Loop PER Payer Technical Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required to report technical contact information for this remittance advice. Example PER BL X TE X TE XXX EM X Variants (all may be used) PER Payer Business Contact Information PER Payer WEB Site If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required If either Communication Number Qualifier (PER-05) or Payer Technical Contact Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required Max use 1 Required PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named BL Technical Department PER-02 93 Payer Technical Contact Name Min 1 Max 60 String (AN) Optional Free-form name Usage notes Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). PER-03 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail TE Telephone Recommended UR Uniform Resource Locator (URL) Use only when there is no central telephone number for the payer entity. PER-04 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 28 128 PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is theextension for the preceding communicationscontact number. FX Facsimile TE Telephone UR Uniform Resource Locator (URL) PER-06 364 Payer Technical Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is theextension for the preceding communicationscontact number. FX Facsimile UR Uniform Resource Locator (URL) PER-08 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 29 128 1000A Payer Identification Loop end PER 1300 Heading Payer Identification Loop PER Payer WEB Site To identify a person or office to whom administrative communications should be directed Usage notes Required when any 2110 loop Healthcare Policy REF Segment is used. If not required by this implementation guide, do not send. This is a direct link to the policy location of the un-secure website. Example PER IC UR XXXX Variants (all may be used) PER Payer Business Contact Information PER Payer Technical Contact Information Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number UR Uniform Resource Locator (URL) PER-04 364 Communication Number Min 1 Max 256 String (AN) Required | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_6 |
Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number UR Uniform Resource Locator (URL) PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable Usage notes This is the payer's WEB site URL where providers can find policy and other related information. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 30 128 1000B Payee Identification Loop Max 1 Required Variants (all may be used) Payer Identification Loop N1 0800 Heading Payee Identification Loop N1 Payee Identification To identify a party by type of organization, name, and code Usage notes Use this N1 loop to provide the name address information of the payee. The identifying reference number is provided in N104. Example N1 PE X FI XXXXXXX Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PE Payee N1-02 93 Payee Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Required if provider is not mandated by NPI. For individual providers as payees, use this qualifier to represent the Social Security Number. XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). This only applies in cases of post payment recovery. See section 1.10.2.16 (Post Payment Recovery) for further information. XX Centers for Medicare and Medicaid Services National Provider Identifier This is REQUIRED when the National Provider Identifier is mandated for use and the payee is a covered health care provider under the mandate. N1-04 67 Payee Identification Code Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 31 128 This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 32 128 N3 1000 Heading Payee Identification Loop N3 Payee Address To specify the location of the named party Usage notes Required when the sender needs to communicate the payee address to a transaction receiver, e.g., a VAN or a clearinghouse. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example N3 XXXXXX X Max use 1 Optional N3-01 166 Payee Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payee Address Line Min 1 Max 55 String (AN) Optional Address information 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 33 128 N4 1100 Heading Payee Identification Loop N4 Payee City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the sender needs to communicate the payee address to a transaction receiver, e.g., a VAN or a clearinghouse. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example N4 XXXXXXX XX XXXXXX XXX Only one of Payee State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Payee City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Payee State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Payee Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 34 128 REF 1200 Heading Payee Identification Loop REF Payee Additional Identification To specify identifying information Usage notes Required when identification of the payee is dependent upon an identification number beyond that supplied in the N1 segment. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example REF D3 XXXXX Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number D3 National Council for Prescription Drug Programs Pharmacy Number PQ Payee Identification TJ Federal Taxpayer's Identification Number This information must be in the N1 segment unless the National Provider ID or the Health Plan Identifier (HPID) or Other Entity Identifier (OEID) was used in N104. For individual providers as payees, use this number to represent the Social Security Number. TJ also represents the Employer Identification Number (EIN). According to the IRS, TIN and EIN can be used interchangeably. REF-02 127 Additional Payee Identifier Min 1 Max 50 String (AN) Required Reference information | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_7 |
used in N104. For individual providers as payees, use this number to represent the Social Security Number. TJ also represents the Employer Identification Number (EIN). According to the IRS, TIN and EIN can be used interchangeably. REF-02 127 Additional Payee Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 35 128 RDM 1400 Heading Payee Identification Loop RDM Remittance Delivery Method To identify remittance delivery when remittance is separate from payment Usage notes Required when BPR01 U or X; and the remittance is to be sent separately from the payment. The payer is responsible to provide the bank with the instructions on how to deliver the remittance information, if not required by this implementation guide, do not send. Payer should coordinate this process with their Originating Depository Financial Institution (ODFI). Example RDM BM XXX XXXX Max use 1 Optional RDM-01 756 Report Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent BM By Mail When used, RDM02 must be used. When BM is used, the remittance information will be mailed to the payee at the address identified in this 1000B loop. EM E-Mail Use with encrypted e-mail. FT File Transfer Use with FTP communications. OL On-Line Use with secured hosted or other electronic delivery. RDM-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name RDM02 is used to contain the name of a third party processor if needed, who would be the first recipient of the remittance. Usage notes When BM is used, the remittance information will be mailed to the attention of this person at the payee's address identified in this 1000B loop. RDM-03 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable RDM03 contains the operative communication number for the delivery method specified in RDM01 (i.e. fax phone number and mail address). Usage notes 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 36 128 1000B Payee Identification Loop end Heading end Contains URL web address or e-mail address. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 37 128 Detail 2000 Header Number Loop Max 1 Optional LX 0030 Detail Header Number Loop LX Header Number To reference a line number in a transaction set Usage notes Required when claim service information is being provided in the transaction. If not required by this implementation guide, do not send. The purpose of LX01 is to provide an identification of a particular grouping of claims for sorting purposes. In the event that claim service information must be sorted, the LX segment must precede each series of claim level and service level segments. This number is intended to be unique within each transaction. Example LX 0 Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 38 128 TS3 0050 Detail Header Number Loop TS3 Provider Summary Information To supply provider-level control information Usage notes TS301 identifies the subsidiary provider. The remaining mandatory elements (TS302 through TS305) must be valid with appropriate data, as defined by the TS3 segment. Only Medicare Part A uses data elements TS313, TS315, TS317, TS318 and TS320 through TS324. Each monetary amount element is for that provider for this facility type code for loop 2000. Required for Medicare Part A or when payers and payees outside the Medicare Part A community need to identify provider subsidiaries whose remittance information is contained in the 835 transactions transmitted to a single provider entity i.e., the corporate office of a hospital chain. If not required by this implementation guide, do not send. Example TS3 XXXXX X 20250130 00000000000 0000000000 0000000 000000000 0000 000 000000000 00 0 00 000000 000000000 Max use 1 Optional TS3-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TS301 is the provider number. Usage notes This is the provider number. TS3-02 1331 Facility Type Code Min 1 Max 2 String (AN) Required Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. Usage notes When reporting a TS3 segment for professional claims and the claims are not all for the same place of service, report a place of service of 11 (Office) as the default value. When reporting a TS3 segment for pharmaceutical claims and the claims are not all for the same place of service, report a place of service of 99 (Other unlisted facility) as the default value. TS3-03 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year TS303 is the last day of the provider's fiscal year. Usage notes 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 39 128 Use this date for the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known, use December 31st of the current year. TS3-04 380 Total Claim Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity TS304 is the total number of claims. Usage notes This is the total number of claims. TS3-05 782 Total Claim Charge Amount Min 1 Max | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_8 |
known, use December 31st of the current year. TS3-04 380 Total Claim Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity TS304 is the total number of claims. Usage notes This is the total number of claims. TS3-05 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount TS305 is the total of reported charges. Usage notes This is the total reported charges for all claims. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all 782 elements. TS3-13 782 Total MSP Payer Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS313 is the total Medicare Secondary Payer (MSP) primary payer amount. Usage notes See TR3 note 3. TS3-15 782 Total Non-Lab Charge Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS315 is the summary of non-lab charges. Usage notes See TR3 note 3. TS3-17 782 Total HCPCS Reported Charge Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS317 is the Health Care Financing Administration Common Procedural Coding System (HCPCS) reported charges. Usage notes See TR3 note 3. TS3-18 782 Total HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 40 128 Monetary amount TS318 is the total Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes See TR3 note 3. TS3-20 782 Total Professional Component Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS320 is the total professional component amount. Usage notes The professional component amount must also be reported in the CAS segment with a Claim Adjustment Reason Code value of 89. See TR3 note 3. TS3-21 782 Total MSP Patient Liability Met Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS321 is the total Medicare Secondary Payer (MSP) patient liability met. Usage notes See TR3 note 3. TS3-22 782 Total Patient Reimbursement Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS322 is the total patient reimbursement. Usage notes See TR3 note 3. TS3-23 380 Total PIP Claim Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS323 is the total periodic interim payment (PIP) number of claims. Usage notes See TR3 note 3. TS3-24 782 Total PIP Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS324 is total periodic interim payment (PIP) adjustment. Usage notes 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 41 128 See TR3 note 3. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 42 128 TS2 0070 Detail Header Number Loop TS2 Provider Supplemental Summary Information To provide supplemental summary control information by provider fiscal year and bill type Usage notes Required when the value of the Total DRG amount is not zero. If not required by this implementation guide, do not send. This segment provides summary information specific to an iteration of the LX loop (Table 2). Each element represents the total value for the provider bill type combination in this loop 2000 iteration. Required for Medicare Part A. If not required by this implementation guide, do not send. Example TS2 00000 000000000000 00000000000000 00000000000 00 00000000 00000000000 000000000000000 000000000 000000 000000000 0000000000000 0000000000000 0000 0000 00 000000000000 000000 000000000 0000000 000 000000000000 000 Max use 1 Optional TS2-01 782 Total DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS201 is the total diagnosis related group (DRG) amount. Usage notes This includes: operating federal-specific amount, operating hospital-specific amount, operating Indirect Medical Education amount, and operating Disproportionate Share Hospital amount. It does not include any operating outlier amount. See TR3 note 2. TS2-02 782 Total Federal Specific Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS202 is the total federal specific amount. Usage notes See TR3 note 2. TS2-03 782 Total Hospital Specific Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS203 is the total hospital specific amount. Usage notes See TR3 note 2. TS2-04 782 Total Disproportionate Share Amount Min 1 Max 15 Decimal number (R) Optional 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 43 128 Monetary amount TS204 is the total disproportionate share amount. Usage notes See TR3 note 2. TS2-05 782 Total Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS205 is the total capital amount. Usage notes This includes: capital federal-specfic amount, hospital federal-specfic amount, hold harmless amount, Indirect Medical Education amount, Disproportionate Share Hospital amount, and the exception amount. It does not include any capital outlier amount. See TR3 note 2. TS2-06 782 Total Indirect Medical Education Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS206 is the total indirect medical education amount. Usage notes See TR3 note 2. TS2-07 380 Total Outlier Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS207 is the total number of outlier days. Usage notes See TR3 note 2. TS2-08 782 Total Day Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS208 is the total day outlier amount. Usage notes See TR3 note 2. TS2-09 782 Total Cost Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS209 is the total cost outlier amount. Usage notes 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 44 128 See TR3 note 2. TS2-10 380 Average DRG Length of Stay Min 1 Max 15 Decimal number (R) Optional | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_9 |
amount. Usage notes 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 44 128 See TR3 note 2. TS2-10 380 Average DRG Length of Stay Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS210 is the diagnosis related group (DRG) average length of stay. Usage notes See TR3 note 2. TS2-11 380 Total Discharge Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS211 is the total number of discharges. Usage notes This is the discharge count produced by PPS PRICER SOFTWARE. See TR3 note 2. TS2-12 380 Total Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS212 is the total number of cost report days. Usage notes See TR3 note 2. TS2-13 380 Total Covered Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS213 is the total number of covered days. Usage notes See TR3 note 2. TS2-14 380 Total Noncovered Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS214 is total number of non-covered days. Usage notes See TR3 note 2. TS2-15 782 Total MSP Pass-Through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS215 is the total Medicare Secondary Payer (MSP) pass- through amount calculated for a non-Medicare payer. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 45 128 Usage notes See TR3 note 2. TS2-16 380 Average DRG weight Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS216 is the average diagnosis-related group (DRG) weight. Usage notes See TR3 note 2. TS2-17 782 Total PPS Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS217 is the total prospective payment system (PPS) capital, federal-specific portion, diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. TS2-18 782 Total PPS Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS218 is the total prospective payment system (PPS) capital, hospital-specific portion, diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. TS2-19 782 Total PPS DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS219 is the total prospective payment system (PPS) disproportionate share, hospital diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 46 128 2100 Claim Payment Information Loop Max 1 Required CLP 0100 Detail Header Number Loop Claim Payment Information Loop CLP Claim Payment Information To supply information common to all services of a claim Usage notes For CLP segment occurrence limitations, see section 1.3.2, Other Usage Limitations. Example CLP XXXX 21 000000000000000 00000000 0000 13 X X X X XXXX 000000000000000 00000000 Max use 1 Required CLP-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment Usage notes Use this number for the patient control number assigned by the provider. If the patient control number is not present on the incoming claim, enter a single zero. The value in CLP01 must be identical to any value received as a Claim Submitter's Identifier on the original claim (CLM01 of the ANSI ASC X12 837, if applicable). This data element is the primary key for posting the remittance information into the provider's database. In the case of pharmacy claims, this is the prescription reference number (field 402-02 in the NCPDP 5.1 format). CLP-02 1029 Claim Status Code Identifier (ID) Required Code identifying the status of an entire claim as assigned by the payor, claim review organization or repricing organization Usage notes To determine the full claim status reference Claim adjustment reason codes in the CAS segment in conjunction with this claim status code. 1 Processed as Primary Use this code if the claim was adjudicated by the current payer as primary regardless of whether any part of the claim was paid. 2 Processed as Secondary Use this code if the claim was adjudicated by the current payer as secondary regardless of whether any part of the claim was paid. 3 Processed as Tertiary Use this code if the claim was adjudicated by the current payer as tertiary (or subsequent) regardless of whether any part of the claim was paid. 4 Denied Usage of this code would apply if the Patient Subscriber is not recognized, and the claim was not forwarded to another payer. 19 Processed as Primary, Forwarded to Additional Payer(s) When this code is used, the Crossover Carrier Name NM1 segment is required. 20 Processed as Secondary, Forwarded to Additional Payer(s) 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 47 128 When this code is used, the Crossover Carrier Name NM1 segment is required. 21 Processed as Tertiary, Forwarded to Additional Payer(s) When this code is used, the Crossover Carrier Name NM1 segment is required. 22 Reversal of Previous Payment See section 1.10.2.8 for usage information. 23 Not Our Claim, Forwarded to Additional Payer(s) Usage of this code would apply if the patient subscriber is not recognized, the claim was not adjudicated by the payer, but other payers are known and the claim has been forwarded to another payer. When this code is used, the Crossover Carrier Name NM1 segment is required. 25 Predetermination Pricing Only - No Payment CLP-03 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLP03 is the amount of submitted charges this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. Use this monetary amount for the submitted charges for this claim. The amount can be positive, zero or negative. An example of a situation with a negative | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_10 |
Monetary amount CLP03 is the amount of submitted charges this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. Use this monetary amount for the submitted charges for this claim. The amount can be positive, zero or negative. An example of a situation with a negative charge is a reversal claim. See section 1.10.2.8 for additional information. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CLP-04 782 Claim Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLP04 is the amount paid this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. See section 1.10.2.9 for information about interest considerations. Use this monetary amount for the amount paid for this claim. It can be positive, zero or negative, but the value in BPR02 may not be negative. CLP-05 782 Patient Responsibility Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CLP05 is the patient responsibility amount. Usage notes Amounts in CLP05 must have supporting adjustments reflected in CAS segments at the 2100 (CLP) or 2110 (SVC) loop level with a Claim Adjustment Group (CAS01) code of PR (Patient Responsibility). Use this monetary amount for the payer's statement of the patient responsibility amount for this claim, which can include such items as deductible, non-covered services, co-pay and co-insurance. This is not used for reversals. See section 1.10.2.8, Reversals and Corrections, for additional information. CLP-06 1032 Claim Filing Indicator Code Identifier (ID) Required 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 48 128 Code identifying type of claim Usage notes For many providers to electronically post the 835 remittance data to their patient accounting systems without human intervention, a unique, provider-specific insurance plan code is needed. This code allows the provider to separately identify and manage the different product lines or contractual arrangements between the payer and the provider. Because most payers maintain the same Originating Company Identifier in the TRN03 or BPR10 for all product lines or contractual relationships, the CLP06 is used by the provider as a table pointer in combination with the TRN03 or BPR10 to identify the unique, provider-specific insurance plan code needed to post the payment without human intervention. The value should mirror the value received in the original claim (2- 005 SBR09 of the 837), if applicable, or provide the value as assigned or edited by the payer. For example the BL from the SBR09 in the 837 would be returned as 12, 13, 15, in the 835 when more details are known. The 837 SBR09 code CI (Commercial Insurance) is generic, if through adjudication the specific type of plan is obtained a more specific code must be returned in the 835. The 837 and 835 transaction code lists for this element are not identical by design. There are some business differences between the two transactions. When a code from the 837 is not available in the 835 another valid code from the 835 must be assigned by the payer. 12 Preferred Provider Organization (PPO) This code is also used for Blue Cross Blue Shield participating provider arrangements. 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance This code is also used for Blue Cross Blue Shield non-participating provider arrangements. 16 Health Maintenance Organization (HMO) Medicare Risk 17 Dental Maintenance Organization AM Automobile Medical CH Champus DS Disability HM Health Maintenance Organization LM Liability Medical MA Medicare Part A MB Medicare Part B MC Medicaid OF Other Federal Program Use this code for the Black Lung Program. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined CLP-07 127 Payer Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CLP07 is the payer's internal control number. Usage notes 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 49 128 Use this number for the payer's internal control number. This number must apply to the entire claim. CLP-08 1331 Facility Type Code Min 1 Max 2 String (AN) Optional Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. Usage notes Since professional or dental claims can have different place of service codes for services within a single claim, default to the place of service of the first service line when the service lines are not all for the same place of service. This number was received in CLM05-1 of the 837 claim. CLP-09 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Optional Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type Usage notes This number was received in CLM05-3 of the 837 Claim. CLP-11 1354 Diagnosis Related Group (DRG) Code Min 1 Max 4 Identifier (ID) Optional Code indicating a patient's diagnosis group based on a patient's illness, diseases, and medical problems CLP-12 380 Diagnosis Related Group (DRG) Weight Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CLP12 is the diagnosis-related group (DRG) weight. Usage notes This is the adjudicated DRG Weight. CLP-13 954 Discharge Fraction Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0 through 100 ) CLP13 is the discharge fraction. Usage notes This is the adjudicated discharge fraction. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 50 128 CAS 0200 Detail Header Number Loop Claim Payment Information Loop CAS Claim Adjustment To supply adjustment reason codes and | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_11 |
adjudicated discharge fraction. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 50 128 CAS 0200 Detail Header Number Loop Claim Payment Information Loop CAS Claim Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Payers must use this CAS segment to report claim level adjustments that cause the amount paid to differ from the amount originally charged. See 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. See the SVC TR3 Note 1 for details about per diem adjustments. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment must be the first non-zero adjustment and is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Required when dollar amounts and or quantities are being adjusted at the claim level. If not required by this implementation guide, do not send. Example CAS PR XX 00000000000 00000 XXX 0000000000000 000 00000000 XXXX 000000000 00000000000000 XXX 000000 000 000 XX 000000000000 000000000000000 XXX 00000 0 00000000000000 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS- 07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 51 128 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer payee contractual agreement or a regulatory requirement resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PI Payor Initiated Reductions Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments). PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the claim level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes See section 1.10.2.4.1 for additional information. 1 29 25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 52 128 A positive value decreases the covered days, and a negative number increases the covered days. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_12 |
(R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 53 128 Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 54 128 Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 55 128 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Patient Name To supply the full name of an individual or organizational entity Usage notes Provide the patient's identification number in NM109. This segment must provide the information from the original claim. For example, when the claim is submitted as an ASC X12 837 transaction, this is the 2010CA loop NM1 Patient Name Segment unless not present on the original claim, then it is the 2010BA loop NM1 Subscriber name segment. The Corrected Patient Insured Name NM1 segment identifies the adjudicated Insured Name and ID information if different than what was submitted on the claim. Example NM1 QC 1 XX XXXXX XXXXXX XXXXXX MR XXXXXX Variants (all may be used) NM1 Insured Name NM1 Corrected Patient Insured Name NM1 Service Provider Name NM1 Crossover Carrier Name NM1 Corrected Priority Payer Name NM1 Other Subscriber Name If either Identification Code Qualifier (NM1-08) or Patient Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual QC Patient NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Patient Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Patient First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Patient Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 56 128 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Patient Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes An example of this is when a Junior and Senior are covered under the same subscriber. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) 34 Social Security Number HN Health Insurance Claim (HIC) Number II Standard Unique Health Identifier for each Individual in the United States Use this code if mandated in a final Federal Rule. MI Member Identification Number MR Medicaid Recipient Identification Number NM1-09 67 Patient Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 57 128 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Insured Name To supply the full name of an individual or organizational entity Usage notes In the case of Medicare and Medicaid, the insured patient is always the subscriber and this segment is not used. Required when the original claim reported the insured or subscriber (for example 837 2010BA loop Subscriber Name NM1 Segment) that is different from the patient. If not required by this implementation guide, do not send. This segment contains the same information as reported on the claim (for example 837 2010BA loop Subscriber Name NM1 Segment when the patient was reported in the 2010CA loop Patient Name NM1 Segment). Example NM1 IL 2 XXXX XXXXX XXXXXX XXXXXX II XXXXX Variants (all may be used) NM1 Patient Name NM1 Corrected Patient Insured Name NM1 Service Provider Name NM1 Crossover Carrier Name NM1 Corrected Priority Payer Name NM1 Other Subscriber Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_13 |
(all may be used) NM1 Patient Name NM1 Corrected Patient Insured Name NM1 Service Provider Name NM1 Crossover Carrier Name NM1 Corrected Priority Payer Name NM1 Other Subscriber Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Subscriber Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 58 128 Individual middle name or initial Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes For example, use when necessary to differentiate between a Junior and Senior under the same contract. NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Not Used when NM102 1. II Standard Unique Health Identifier for each Individual in the United States Use this code if mandated in a final Federal Rule. MI Member Identification Number The code MI is intended to identify that the subscriber's identification number as assigned by the payer will be conveyed in NM109. Payers use different terminology to convey the same number, therefore, the 835 workgroup recommends using MI (Member Identification number) to convey the same categories of numbers as represented in the 837 IGs for the inbound claims. NM1-09 67 Subscriber Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 59 128 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Corrected Patient Insured Name To supply the full name of an individual or organizational entity Usage notes Since the patient is always the insured for Medicare and Medicaid, this segment always provides corrected patient information for Medicare and Medicaid. For other carriers, this will always be the corrected insured information. Required when needed to provide corrected information about the patient or insured. If not required by this implementation guide, do not send. Example NM1 74 2 X XXXXXX X X C XXX Variants (all may be used) NM1 Patient Name NM1 Insured Name NM1 Service Provider Name NM1 Crossover Carrier Name NM1 Corrected Priority Payer Name NM1 Other Subscriber Name If either Identification Code Qualifier (NM1-08) or Corrected Insured Identification Indicator (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 74 Corrected Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Corrected Patient or Insured Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Corrected Patient or Insured First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Corrected Patient or Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 60 128 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Corrected Patient or Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) C Insured's Changed Unique Identification Number NM1-09 67 Corrected Insured Identification Indicator Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 61 128 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Service Provider Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the rendering provider. An identification number is provided in NM109. This information is provided to facilitate identification of the claim within a payee's system. Other providers (e.g., Referring provider, supervising provider) related to the claim but not directly related to the payment are not supported and are not necessary for claim identification. Required when the rendering provider is different from the payee. If not required by this implementation guide, do not send. Example NM1 82 1 XXXX XX XXXXXX XXXXXX BS XXXXXX Variants (all may be used) NM1 Patient Name NM1 Insured Name NM1 Corrected Patient Insured Name NM1 Crossover Carrier Name NM1 Corrected Priority Payer Name NM1 Other Subscriber Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_14 |
last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 62 128 Individual middle name or initial Usage notes If this data element is used and contains only one character, it represents the middle initial. NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) BD Blue Cross Provider Number BS Blue Shield Provider Number FI Federal Taxpayer's Identification Number This is the preferred ID until the National Provider ID is mandated and applicable. For individual providers as payees, use this qualifier to represent the Social Security Number. MC Medicaid Provider Number PC Provider Commercial Number SL State License Number UP Unique Physician Identification Number (UPIN) XX Centers for Medicare and Medicaid Services National Provider Identifier Required value if the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate. Otherwise, one of the other listed codes may be used. NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 63 128 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Crossover Carrier Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the crossover carrier. Provide any reference numbers in NM109. The crossover carrier is defined as any payer to which the claim is transferred for further payment after being finalized by the current payer. Required when the claim is transferred to another carrier or coverage (CLP02 equals 19, 20, 21 or 23). If not required by this implementation guide, do not send. Example NM1 TT 2 XXXXXX NI XXXX Variants (all may be used) NM1 Patient Name NM1 Insured Name NM1 Corrected Patient Insured Name NM1 Service Provider Name NM1 Corrected Priority Payer Name NM1 Other Subscriber Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual TT Transfer To NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Crossover Carrier Name Min 1 Max 60 String (AN) Required Individual last name or organizational name Usage notes Name of the crossover carrier associated with this claim. NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) AD Blue Cross Blue Shield Association Plan Code FI Federal Taxpayer's Identification Number NI National Association of Insurance Commissioners (NAIC) Identification This is the preferred ID unless XV is used. PI Payor Identification 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 64 128 PP Pharmacy Processor Number XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used. NM1-09 67 Crossover Carrier Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 65 128 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Corrected Priority Payer Name To supply the full name of an individual or organizational entity Usage notes Provide any reference numbers in NM109. Use of this segment identifies the priority payer. Do not use this segment when the Crossover Carrier NM1 segment is used. Required when current payer believes that another payer has priority for making a payment and the claim is not being automatically transferred to that payer. If not required by this implementation guide, do not send. Example NM1 PR 2 XXXX NI XXXXXXX Variants (all may be used) NM1 Patient Name NM1 Insured Name NM1 Corrected Patient Insured Name NM1 Service Provider Name NM1 Crossover Carrier Name NM1 Other Subscriber Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Corrected Priority Payer Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) AD Blue Cross Blue Shield Association Plan Code FI Federal Taxpayer's Identification Number NI National Association of Insurance Commissioners (NAIC) Identification This is the preferred ID unless XV is used. PI Payor Identification PP Pharmacy Processor Number XV Centers for Medicare and Medicaid Services PlanID 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 66 128 Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used. NM1-09 67 Corrected Priority Payer Identification Number Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 67 128 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Other Subscriber Name To supply the full name of an individual or organizational entity | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_15 |
8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 67 128 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes This is the name and ID number of the other subscriber when a corrected priority payer has been identified. When used, either the name or ID must be supplied. Required when a corrected priority payer has been identified in another NM1 segment AND the name or ID of the other subscriber is known. If not required by this implementation guide, do not send. Example NM1 GB 1 XXXXXX XXXXX XXXX XXXXX FI XX Variants (all may be used) NM1 Patient Name NM1 Insured Name NM1 Corrected Patient Insured Name NM1 Service Provider Name NM1 Crossover Carrier Name NM1 Corrected Priority Payer Name If either Identification Code Qualifier (NM1-08) or Other Subscriber Identifier (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual GB Other Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Subscriber Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name Usage notes At least one of NM103 or NM109 must be present. NM1-04 1036 Other Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 68 128 Individual middle name or initial Usage notes When only one character is present this is assumed to be the middle initial. NM1-07 1039 Other Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Not Used when NM102 1. II Standard Unique Health Identifier for each Individual in the United States Use this code if mandated in a final Federal Rule. MI Member Identification Number Use this code when supplying the number used for identification of the subscriber in NM109. NM1-09 67 Other Subscriber Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes At least one of NM103 or NM109 must be present. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 69 128 MIA 0330 Detail Header Number Loop Claim Payment Information Loop MIA Inpatient Adjudication Information To provide claim-level data related to the adjudication of Medicare inpatient claims Usage notes When used outside of the Medicare and Medicaid community only MIA01, 05, 20, 21, 22 and 23 may be used. Either MIA or MOA may appear, but not both. This segment must not be used for covered days or lifetime reserve days. For covered or lifetime reserve days, use the Supplemental Claim Information Quantities Segment in the Claim Payment Loop. All situational quantities and or monetary amounts in this segment are required when the value of the item is different than zero. Required for all inpatient claims when there is a need to report Remittance Advice Remark Codes at the claim level or, the claim is paid by Medicare or Medicaid under the Prospective Payment System (PPS). If not required by this implementation guide, do not send. Example MIA 00000000000000 00000 0000000000000 0000000000 000 XXX 00000000000000 00000000000000 00000000000 0000 00000000 000000000000 0000000000 000000000 0 000000000000 000 00000 00000 000000000000 00000 0000 000 XXXXX XX XXXXXX XXXXXX 00000000 Max use 1 Optional MIA-01 380 Covered Days or Visits Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity MIA01 is the covered days. Usage notes Implementers utilizing the MIA segment always transmit the number zero. See the QTY segment at the claim level for covered days or visits count. MIA-02 782 PPS Operating Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA02 is the Prospective Payment System (PPS) Operating Outlier amount. Usage notes See TR3 note 4. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MIA-03 380 Lifetime Psychiatric Days Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA03 is the lifetime psychiatric days. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 70 128 MIA-04 782 Claim DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA04 is the Diagnosis Related Group (DRG) amount. MIA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA05 is the Claim Payment Remark Code. See Code Source 411. MIA-06 782 Claim Disproportionate Share Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA06 is the disproportionate share amount. MIA-07 782 Claim MSP Pass-through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA07 is the Medicare Secondary Payer (MSP) pass-through amount. MIA-08 782 Claim PPS Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA08 is the total Prospective Payment System (PPS) capital amount. MIA-09 782 PPS-Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_16 |
MIA-09 782 PPS-Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 71 128 MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 72 128 Monetary amount MIA19 is the professional component amount billed but not payable. MIA-20 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA20 is the Claim Payment Remark Code. See Code Source 411. MIA-21 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA21 is the Claim Payment Remark Code. See Code Source 411. MIA-22 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 73 128 MOA 0350 Detail Header Number Loop Claim Payment Information Loop MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required when the outpatient institutional claim reimbursement rate is not zero for a Medicare or Medicaid claim. If not required by this implementation guide, do not send. Required for outpatient professional claims where there is a need to report a Remittance Advice Remark Code at the claim level or when the payer is Medicare or Medicaid and MOA01, 02, 08 or 09 are non-zero. If not required by this implementation guide, do not send. Either MIA or MOA may appear, but not both. All situational quantities and or monetary amounts in this segment are;required when the value of the item is different than zero. Example MOA 00000 0000000000 XXX XXXXXX XXXXX X XXX 00000 000 0000 Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0 through 100 ) MOA01 is the reimbursement rate. MOA-02 782 Claim HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 74 128 MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_17 |
Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 Claim ESRD Payment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 75 128 REF 0400 Detail Header Number Loop Claim Payment Information Loop REF Other Claim Related Identification To specify identifying information Usage notes Required when additional reference numbers specific to the claim in the CLP segment are provided to identify information used in the process of adjudicating this claim. If not required by this implementation guide, do not send. Example REF CE XXXXXX Variants (all may be used) REF Rendering Provider Identification Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1L Group or Policy Number Use this code when conveying the Group Number in REF02. 1W Member Identification Number 6P Group Number This is the Other Insured Group Number. This is required when a Corrected Priority Payer is identified in the NM1 segment and the Group Number of the other insured for that payer is known. 9A Repriced Claim Reference Number 9C Adjusted Repriced Claim Reference Number 28 Employee Identification Number BB Authorization Number Use this qualifier only when supplying an authorization number that was assigned by the adjudication process and was not provided prior to the services. Do not use this qualifier when reporting the same number as reported in the claim as the prior authorization or pre-authorization number. CE Class of Contract Code See section 1.10.2.15 for information on the use of Class of Contract Code. EA Medical Record Identification Number F8 Original Reference Number When this is a correction claim and CLP07 does not equal the CLP07 value from the original claim payment, one iteration of this REF segment using this qualifier is REQUIRED to identify the original claim CLP07 value in REF02. See section 1.10.2.8, Reversals and Corrections, for additional information. G1 Prior Authorization Number Use this qualifier when reporting the number received with the original claim as a pre- authorization number (in the 837 that was at table 2, position 180, REF segment, using the same qualifier of G1). G3 Predetermination of Benefits Identification Number IG Insurance Policy Number Use this code when conveying the Policy Number in REF02. SY Social Security Number 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 76 128 REF-02 127 Other Claim Related Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 77 128 REF 0400 Detail Header Number Loop Claim Payment Information Loop REF Rendering Provider Identification To specify identifying information Usage notes The NM1 segment always contains the primary reference number. Required when additional rendering provider identification numbers not already reported in the Provider NM1 segment for this claim were submitted on the original claim and impacted adjudication. If not required by this implementation guide, do not send. Example REF 1J XX Variants (all may be used) REF Other Claim Related Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1A Blue Cross Provider Number 1B Blue Shield Provider Number 1C Medicare Provider Number 1D Medicaid Provider Number 1G Provider UPIN Number 1H CHAMPUS Identification Number 1J Facility ID Number D3 National Council for Prescription Drug Programs Pharmacy Number G2 Provider Commercial Number LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 78 128 DTM 0500 Detail Header Number Loop Claim Payment Information Loop DTM Statement From or To Date To specify pertinent dates and times Usage notes Dates at the claim level apply to the entire claim, including all service lines. Dates at the service line level apply only to the service line where they appear. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. For retail pharmacy claims, the Claim Statement Period Start Date is equivalent to the prescription filled date. Required when the "Statement From or To Dates" are not supplied at the service (2110 loop) level. If not required by this implementation guide, may be provided at senders discretion, but cannot be required by the receiver. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM 233 20250130 Variants (all may be used) DTM Coverage Expiration Date DTM Claim Received Date Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 232 Claim | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_18 |
the use of future dates is allowed. Example DTM 233 20250130 Variants (all may be used) DTM Coverage Expiration Date DTM Claim Received Date Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 232 Claim Statement Period Start If the claim statement period start date is conveyed without a subsequent claim statement period end date, the end date is assumed to be the same as the start date. This date or code 233 is required when service level dates are not provided in the remittance advice. 233 Claim Statement Period End If a claim statement period end date is conveyed without a claim statement period start date, then the start date is assumed to be different from the end date but not conveyed at the payer's discretion. See the note on code 232. DTM-02 373 Claim Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 79 128 DTM 0500 Detail Header Number Loop Claim Payment Information Loop DTM Coverage Expiration Date To specify pertinent dates and times Usage notes Required when payment is denied because of the expiration of coverage. If not required by this implementation guide, do not send. Example DTM 036 20250130 Variants (all may be used) DTM Statement From or To Date DTM Claim Received Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 036 Expiration DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the expiration date of the patient's coverage. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 80 128 DTM 0500 Detail Header Number Loop Claim Payment Information Loop DTM Claim Received Date To specify pertinent dates and times Usage notes Required whenever state or federal regulations or the provider contract mandate interest payment or prompt payment discounts based upon the receipt date of the claim by the payer. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example DTM 050 20250130 Variants (all may be used) DTM Statement From or To Date DTM Coverage Expiration Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the date that the claim was received by the payer. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 81 128 PER 0600 Detail Header Number Loop Claim Payment Information Loop PER Claim Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when there is a claim specific communications contact. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800)555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number. Example PER CX X FX XXXXX FX XXXXXX EX XXXXX If either Communication Number Qualifier (PER-05) or Claim Contact Communications Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number Extension (PER-08) is present, then the other is required Max use 2 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Claim Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 82 128 EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Communication Number Extension Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 83 128 AMT 0620 Detail Header Number Loop Claim Payment Information Loop AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send receive one AMT for each applicable non-zero value. Do not report any zero values. Required when the value of any specific | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_19 |
Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send receive one AMT for each applicable non-zero value. Do not report any zero values. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMT ZO 0000000 Max use 13 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount AU Coverage Amount Use this monetary amount to report the total covered charges. This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan. This excludes charges considered not covered (i.e. per day television or telephone charges) but includes reductions to payments of covered services (i.e. reductions for amounts over fee schedule and patient deductibles). D8 Discount Amount Prompt Pay Discount Amount See section 1.10.2.9 for additional information. DY Per Day Limit F5 Patient Amount Paid Use this monetary amount for the amount the patient has already paid. I Interest See section 1.10.2.9 for additional information. NL Negative Ledger Balance Used only by Medicare Part A and Medicare Part B. T Tax T2 Total Claim Before Taxes Used only when tax also applies to the claim. ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 AMT-02 782 Claim Supplemental Information Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 84 128 Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 85 128 QTY 0640 Detail Header Number Loop Claim Payment Information Loop QTY Claim Supplemental Information Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send one QTY for each non-zero value. Do not report any zero values. Required when the value of a specific quantity identified by the QTY01 qualifier is non- zero. If not required by this implementation guide, do not send. Example QTY CA 00000 Max use 14 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity CA Covered - Actual CD Co-insured - Actual LA Life-time Reserve - Actual LE Life-time Reserve - Estimated NE Non-Covered - Estimated NR Not Replaced Blood Units OU Outlier Days PS Prescription VS Visits ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Claim Supplemental Information Quantity Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 86 128 2110 Service Payment Information Loop Max 999 Optional SVC 0700 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop SVC Service Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO78 25 ). See section 1.10.2.4.1 for additional information. See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information. Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send. Example SVC AD XXXX XX XX XX XX 00000000000 0000000000 XX XXX 0000000000 ER XXXXX XX XX XX XX X 00000000 Max use 1 Required SVC-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132). Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7. AD American Dental Association Codes ER Jurisdiction Specific Procedure and Supply Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. IV Home Infusion EDI Coalition (HIEC) Product Service Code 1 29 25, 8:52 | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_20 |
the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. IV Home Infusion EDI Coalition (HIEC) Product Service Code 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 87 128 This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. N4 National Drug Code in 5-4-2 Format N6 National Health Related Item Code in 4-6 Format This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names National Health Related Item Code in 4-6 Format Codes as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. NU National Uniform Billing Committee (NUBC) UB92 Codes UI U.P.C. Consumer Package Code (1-5-5) This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names U.P.C. Consumer Package Code (1-5-5) Codes as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. WK Advanced Billing Concepts (ABC) Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used in transactions covered under HIPAA by parties registered in the pilot project and their trading partners. C003-02 234 Adjudicated Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 88 128 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. SVC-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC02 is the submitted service charge. Usage notes Use this monetary amount for the submitted service charge amount. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. SVC-03 782 Line Item Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC03 is the amount paid this service. Usage notes Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. See 1.10.2.1, Balancing, for additional information. SVC-04 234 National Uniform Billing Committee Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service SVC04 is the National Uniform Billing Committee Revenue Code. Usage notes If the original claim and adjudication only referenced an NUBC revenue code, that is supplied in SVC01 and this element is not used. SVC-05 380 Units of Service Paid Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC05 is the paid units of service. Usage notes If not present, the value is assumed to be one. SVC-06 C003 Composite Medical Procedure Identifier Max use 1 Optional 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 89 128 To identify a medical procedure by its standardized codes and applicable modifiers - SVC06 is the original submitted medical procedure. Usage notes Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send. C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7. AD American Dental Association Codes ER Jurisdiction Specific Procedure and Supply Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_21 |
Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes WK Advanced Billing Concepts (ABC) Codes This qualifier can only be used in transactions covere under HIPAA by parties registered in the pilot project and their trading partners. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 90 128 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVC-07 380 Original Units of Service Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC07 is the original submitted units of service. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 91 128 DTM 0800 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop DTM Service Date To specify pertinent dates and times Usage notes Dates at the service line level apply only to the service line where they appear. If used for inpatient claims and no service date was provided on the claim then report the through date from the claim level. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. Required when claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. For retail pharmacy claims, the service date is equivalent to the prescription filled date. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM 151 20250130 Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 150 Service Period Start This qualifier is required for reporting the beginning of multi-day services. If not required by this implementation guide, do not send. 151 Service Period End This qualifier is required for reporting the end of multi-day services. If not required by this implementation guide, do not send. 472 Service This qualifier is required to indicate a single day service. If not required by this implementation guide, do not send. DTM-02 373 Service Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 92 128 CAS 0900 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop CAS Service Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes An example of this level of CAS is the reduction for the part of the service charge that exceeds the usual and customary charge for the service. See sections 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02). If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS PR XXXXX 0000000000 00 XXXXX 0000 000 X 000 0 00 XXX 0000000000000 0000000000 XXXX 0000000000 00000 0 XX 0000000000000 000000000000000 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_22 |
(CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS PR XXXXX 0000000000 00 XXXXX 0000 000 X 000 0 00 XXX 0000000000000 0000000000 XXXX 0000000000 00000 0 XX 0000000000000 000000000000000 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS- 07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 93 128 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer payee agreement or a regulatory requirement has resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PI Payor Initiated Reductions Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments). PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03 and CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 94 128 A positive number decreases paid units, and a negative value increases paid units. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 95 128 CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made 1 29 25, 8:52 | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_23 |
Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 96 128 Usage notes See CAS02. CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 97 128 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Service Identification To specify identifying information Usage notes Required when related service specific reference identifiers were used in the process of adjudicating this service. If not required by this implementation guide, do not send. Example REF 1S X Variants (all may be used) REF Line Item Control Number REF Rendering Provider Information REF HealthCare Policy Identification Max use 8 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1S Ambulatory Patient Group (APG) Number APC Ambulatory Payment Classification BB Authorization Number E9 Attachment Code G1 Prior Authorization Number G3 Predetermination of Benefits Identification Number LU Location Number This is the Payer's identification for the provider location. This is REQUIRED when the specific site of service affected the payment of the claim. RB Rate code number Rate Code Number reflects Ambulatory Surgical Center (ASC) rate for Medicare, either 0, 50, 100 or 150. REF-02 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 98 128 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Line Item Control Number To specify identifying information Usage notes This is the Line Item Control Number submitted in the 837, which is utilized by the provider for tracking purposes. See section 1.10.2.11 and 1.10.2.14.1 for additional information on usage with split claims or services. Note - the value in REF02 can include alpha characters. Required when a Line Item Control Number was received on the original claim or when claim or service line splitting has occurred. If not required by this implementation guide, do not send. Example REF 6R XXXXX Variants (all may be used) REF Service Identification REF Rendering Provider Information REF HealthCare Policy Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 99 128 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Rendering Provider Information To specify identifying information Usage notes Required when the rendering provider for this service is different than the rendering provider applicable at the claim level. If not required by this implementation guide, do not send. Example REF HPI XXXXXX Variants (all may be used) REF Service Identification REF Line Item Control Number REF HealthCare Policy Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1A Blue Cross Provider Number 1B Blue Shield Provider Number 1C Medicare Provider Number 1D Medicaid Provider Number 1G Provider UPIN Number 1H CHAMPUS Identification Number 1J Facility ID Number D3 National Council for Prescription Drug Programs Pharmacy Number G2 Provider Commercial Number HPI Centers for Medicare and Medicaid Services National Provider Identifier This qualifier is REQUIRED when the National Provider Identifier is mandated for use and the provider is a covered health care provider under that mandate. SY Social Security Number TJ Federal Taxpayer's Identification Number REF-02 127 Rendering Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 100 128 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF HealthCare Policy Identification To specify identifying information Usage notes Required when; The payment is adjusted in accordance with the Payer's published Healthcare Policy Code list and A Claim Adjustment Reason Code identified by the notation, "refer to 835 Healthcare Policy identification segment", in the Claim Adjustment Reason Code List is present in a related CAS segment and The payer has a published enumerated healthcare policy code list available to healthcare providers via an un-secure public website and The payer wishes to supply this policy detail to reduce provider inquiries. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Healthcare Policy - A clinical statutory rule use to determine claim adjudication that cannot be explained by the sole use of a claim adjustment reason code in the CAS segment and Remittance Advise Remark code when appropriate. The term Healthcare Policy is intended to include Medical Review Policy, Dental Policy Review, Property and Casualty Policies, Workers Comp Policies and Pharmacy Policies for example Medicare LMRP's.( Local Medicare Review policies) and NCD (National Coverage Determinations). This policy segment must not be used to | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_24 |
Advise Remark code when appropriate. The term Healthcare Policy is intended to include Medical Review Policy, Dental Policy Review, Property and Casualty Policies, Workers Comp Policies and Pharmacy Policies for example Medicare LMRP's.( Local Medicare Review policies) and NCD (National Coverage Determinations). This policy segment must not be used to provide a proprietary explanation code or reason for adjustment. Supply the Healthcare policy identifier in REF02 as provided by the payer's published Healthcare policy code list. This policy code will be used to explain the policy used to process the claim which resulted in the adjusted payment. If this segment is used, the PER (Payer Web Site) segment is required to provide an un- secure WEB contact point where the provider can access the payer's enumerated, published healthcare policy. Example REF 0K XXXXXX Variants (all may be used) REF Service Identification REF Line Item Control Number REF Rendering Provider Information Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0K Policy Form Identifying Number REF-02 127 Healthcare Policy Identification Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 101 128 AMT 1100 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop AMT Service Supplemental Amount To indicate the total monetary amount Usage notes This segment is used to convey information only. It is not part of the financial balancing of the 835. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMT ZO 0000 Max use 9 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount B6 Allowed - Actual Allowed amount is the amount the payer deems payable prior to considering patient responsibility. KH Deduction Amount Late Filing Reduction T Tax T2 Total Claim Before Taxes Use this monetary amount for the service charge before taxes. This is only used when there is an applicable tax amount on this service. ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 AMT-02 782 Service Supplemental Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 102 128 QTY 1200 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop QTY Service Supplemental Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Required when new Federal Medicare or Medicaid mandates require Quantity counts and value of specific quantities identified in the QTY01 qualifier are non-zero. If not required by this implementation guide, do not send. Example QTY ZL 00000000 Max use 6 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Service Supplemental Quantity Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 103 128 2110 Service Payment Information Loop end 2100 Claim Payment Information Loop end 2000 Header Number Loop end Detail end LQ 1300 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop LQ Health Care Remark Codes To identify standard industry codes Usage notes Use this segment to provide informational remarks only. This segment has no impact on the actual payment. Changes in claim payment amounts are provided in the CAS segments. Required when remark codes or NCPDP Reject Payment codes are necessary for the provider to fully understand the adjudication message for a given service line. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example LQ HE X If Code List Qualifier Code (LQ-01) is present, then Remark Code (LQ-02) is required Max use 99 Optional LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list HE Claim Payment Remark Codes RX National Council for Prescription Drug Programs Reject Payment Codes LQ-02 1271 Remark Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 104 128 Summary PLB 0100 Summary PLB Provider Adjustment To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service Usage notes These adjustments can either decrease the payment (a positive number) or increase the payment (a negative number). Zero dollar adjustments are not allowed. Some examples of PLB adjustments are a Periodic Interim Payment (loans and loan repayment) or a capitation payment. Multiple adjustments can be placed in one PLB segment, grouped by the provider identified in PLB01 and the period identified in PLB02. Although the PLB | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_25 |
number). Zero dollar adjustments are not allowed. Some examples of PLB adjustments are a Periodic Interim Payment (loans and loan repayment) or a capitation payment. Multiple adjustments can be placed in one PLB segment, grouped by the provider identified in PLB01 and the period identified in PLB02. Although the PLB reference numbers are not standardized, refer to 1.10.2.9 (Interest and Prompt Payment Discounts), 1.10.2.10 (Capitation and Related Payments or Adjustments), 1.10.2.12 (Balance Forward Processing), 1.10.2.16 (Post Payment Recovery) and 1.10.2.17 (Claim Overpayment Recovery) for code suggestions and usage guidelines. The codes and notations under PLB03 and its components apply equally to PLB05, 07, 09, 11 and 13. Required when reporting adjustments to the actual payment that are NOT specific to a particular claim or service. If not required by this implementation guide, do not send. Example PLB XXXXXX 20250130 LE XXXX 000000000000000 XX XX X 000000000 XX XXXXX 000000000000000 XX XXXX 000 0 XX X 00000000 XX XXXX 00000000 If either Adjustment Identifier (PLB-05) or Provider Adjustment Amount (PLB-06) is present, then the other is required If either Adjustment Identifier (PLB-07) or Provider Adjustment Amount (PLB-08) is present, then the other is required If either Adjustment Identifier (PLB-09) or Provider Adjustment Amount (PLB-10) is present, then the other is required If either Adjustment Identifier (PLB-11) or Provider Adjustment Amount (PLB-12) is present, then the other is required If either Adjustment Identifier (PLB-13) or Provider Adjustment Amount (PLB-14) is present, then the other is required Max use 1 Optional PLB-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB01 is the provider number assigned by the payer. Usage notes When the National Provider Identifier (NPI) is mandated and the provider is a covered health care provider under that mandate, this must be the NPI assigned to the provider. Until the NPI is mandated, this is the provider identifier as assigned by the payer. PLB-02 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 105 128 year PLB02 is the last day of the provider's fiscal year. Usage notes This is the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known by the payer, use December 31st of the current year. PLB-03 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB03 is the adjustment information as defined by the payer. Max use 1 Required C042-01 426 Adjustment Reason Code Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment 50 Late Charge This is the Late Claim Filing Penalty or Medicare Late Cost Report Penalty. 51 Interest Penalty Charge This is the interest assessment for late filing. 72 Authorized Return This is the provider refund adjustment. This adjustment acknowledges a refund received from a provider for previous overpayment. PLB03-2 must always contain an identifying reference number when the value is used. PLB04 must contain a negative value. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. 90 Early Payment Allowance AH Origination Fee This is the claim transmission fee. This is used for transmission fees that are not specific to or dependent upon individual claims. AM Applied to Borrower's Account See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. Use this code to identify the loan repayment amount. This is capitation specific. AP Acceleration of Benefits This is the accelerated payment amount or withholding. Withholding or payment identification is indicated by the sign of the amount in PLB04. A positive value represents a withholding. A negative value represents a payment. B2 Rebate This adjustment code applies when a provider has remitted an overpayment to a health plan in excess of the amount requested by the health plan. The amount accepted by the health plan is reported using code 72 (Authorized Return) and offset by the amount with code WO (Overpayment Recovery). The excess returned by the provider is reported as a negative amount using code B2, returning the excess funds to the provider. B3 Recovery Allowance This represents the check received from the provider for overpayments generated by payments from other payers. This code differs from the provider refund adjustment identified with code 72. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. BD Bad Debt Adjustment This is the bad debt passthrough. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 106 128 BN Bonus This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. C5 Temporary Allowance This is the tentative adjustment. CR Capitation Interest This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. CS Adjustment Provide supporting identification information in PLB03-2. CT Capitation Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. CV Capital Passthru CW Certified Registered Nurse Anesthetist Passthru DM Direct Medical Education Passthru E3 Withholding See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. FB Forwarding Balance This is the balance forward. A negative value in PLB04 represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice. A reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information. FC Fund Allocation This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_26 |
payment advice. A positive value represents a balance being applied from a previous payment advice. A reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information. FC Fund Allocation This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. The specific fund must be identified in PLB03-2. GO Graduate Medical Education Passthru HM Hemophilia Clotting Factor Supplement IP Incentive Premium Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. IR Internal Revenue Service Withholding IS Interim Settlement This is the interim rate lump sum adjustment. J1 Nonreimbursable This offsets the claim or service level data that reflects what could be paid if not for demonstration program or other limitation that prevents issuance of payment. L3 Penalty This is the capitation-related penalty. Withholding or release is identified by the sign in PLB04. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. L6 Interest Owed This is the interest paid on claims in this 835. Support the amounts related to this adjustment by 2-062 AMT amounts, where AMT01 is "I". LE Levy IRS Levy LS Lump Sum This is the disproportionate share adjustment, indirect medical education passthrough, non-physician passthrough, passthrough lump sum adjustment, or other passthrough amount. The specific type of lump sum adjustment must be identified in PLB03-2. OA Organ Acquisition Passthru OB Offset for Affiliated Providers 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 107 128 Identification of the affiliated providers must be made on PLB03-2. PI Periodic Interim Payment This is the periodic interim lump sum payments and reductions (PIP). The payments are made to a provider at the beginning of some period in advance of claims. These payments are advances on the expected claims for the period. The reductions are the recovery of actual claims payments during the period. For instance, when a provider has a PIP payment, claims within this remittance advice covered by that payment would be offset using this code to remove the claim payment from the current check. The sign of the amount in PLB04 determines whether this is a payment (negative) or reduction (positive). This payment and recoupment is effectively a loan to the provider and loan repayment. See section 1.10.2.5, Advance Payments and Reconciliation, for additional information. PL Payment Final This is the final settlement. RA Retro-activity Adjustment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. RE Return on Equity SL Student Loan Repayment TL Third Party Liability This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. WO Overpayment Recovery This is the recovery of previous overpayment. An identifying number must be provided in PLB03-2. See the notes on codes 72 and B3 for additional information about balancing against a provider refund. WU Unspecified Recovery Medicare is currently using this code to represent penalty collections withheld for the IRS (an outside source). C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Use when necessary to assist the receiver in identifying, tracking or reconcilling the adjustment. See sections 1.10.2.10 (Capitation and Related Payments), 1.10.2.5 (Advanced Payments and Reconciliation) and 1.10.2.12 (Balance Forward Processing) for further information. PLB-04 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount PLB04 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. PLB-05 C042 Adjustment Identifier Max use 1 Optional 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 108 128 To provide the category and identifying reference information for an adjustment - PLB05 is the adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-06 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB06 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-07 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB07 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-08 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB08 is the adjustment amount. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 109 128 Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-09 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB09 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_27 |
hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 109 128 Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-09 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB09 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-10 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB10 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-11 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB11 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 110 128 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-12 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB12 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-13 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB13 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-14 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB14 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 111 128 Summary end SE 0200 Summary SE Transaction Set Trailer To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments) Example SE 000 0001 Max use 1 Required SE-01 96 Transaction Segment Count Min 1 Max 10 Numeric (N0) Required Total number of segments included in a transaction set including ST and SE segments SE-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Numbers in ST02 and SE02 must be identical. The originator assigns the Transaction Set Control Number, which must be unique within a functional group (GS-GE). This unique number also aids in error resolution research. 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 112 128 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE 00000 000000000 Max use 1 Required GE-01 97 Number of Transaction Sets Included Min 1 Max 6 Numeric (N0) Required Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element GE-02 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 113 128 IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA 00 000000000 Max use 1 Required IEA-01 I16 Number of Included Functional Groups Min 1 Max 5 Numeric (N0) Required A count of the number of functional groups included in an interchange IEA-02 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 114 128 EDI Samples Example 1: Dollars and Data Sent Separately ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 112233 BPR I 1100 C ACH CCP 01 888999777 DA 24681012 1935665544 01 111333555 DA 144444 20190316 TRN 1 71700666555 1935665544 DTM 405 20190314 N1 PR RUSHMORE LIFE N3 10 SOUTH AVENUET N4 RAPID CITY SD 55111 PER BL JOHN WAYNE TE 8005551212 EX 123 N1 PE ACME MEDICAL CENTER XX 5544667733 REF TJ 777667755 LX 1 CLP 5554555444 1 800 500 300 12 94060555410000 11 1 NM1 QC 1 BUDD WILLIAM MI 33344555510 AMT AU 800 SVC HC 99211 800 500 DTM 472 20190301 CAS PR 1 300 AMT B6 800 CLP 8765432112 1 1200 600 600 12 9407779923000 11 | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_28 |
5544667733 REF TJ 777667755 LX 1 CLP 5554555444 1 800 500 300 12 94060555410000 11 1 NM1 QC 1 BUDD WILLIAM MI 33344555510 AMT AU 800 SVC HC 99211 800 500 DTM 472 20190301 CAS PR 1 300 AMT B6 800 CLP 8765432112 1 1200 600 600 12 9407779923000 11 1 NM1 QC 1 SETTLE SUSAN MI 44455666610 AMT AU 1200 SVC HC 93555 1200 600 DTM 472 20190310 CAS PR 1 600 AMT B6 1200 SE 26 112233 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 115 128 Example 2: Multiple Claims Single Check ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 35681 BPR I 810.8 C CHK 20190331 TRN 1 12345 1512345678 REF EV XYZ CLEARINGHOUSE N1 PR DENTAL OF ABC N3 225 MAIN STREET N4 CENTERVILLE PA 17111 PER BL JANE DOE TE 9005555555 N1 PE BAN DDS LLC XX 9999947036 REF TJ 212121212 LX 1 CLP 7722337 1 226 132 12 119932404007801 11 1 NM1 QC 1 DOE SANDY MI SJD11112 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190324 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 119 74 12 119932404007801 11 1 NM1 QC 1 DOE SALLY MI SJD11111 NM1 IL 1 DOE JOHN MI SJD11111 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 74 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 226 108 24 12 119932404007801 11 1 NM1 QC 1 SMITH SALLY MI SJD11113 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 116 128 AMT B6 25 SVC AD D0220 25 0 DTM 472 20190324 CAS PR 3 14 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 0 DTM 472 20190324 CAS PR 3 10 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 1145 14 902 12 119932404007801 11 1 NM1 QC 1 SMITH SAM MI SJD11116 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 14 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 45 11 AMT B6 14 SVC AD D2790 940 0 DTM 472 20190324 CAS PR 3 756 CAS CO 45 184 SVC AD D2950 180 0 DTM 472 20190324 CAS PR 3 146 CAS CO 45 34 CLP 7722337 1 348 16.8 44.2 12 119932404007801 11 1 NM1 QC 1 JONES SAM MI SJD11122 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 28 SVC AD D4342 125 0 DTM 472 20190313 CAS CO 45 125 SVC AD D4381 43 0 DTM 472 20190313 CAS PR 3 33 CAS CO 45 10 SVC AD D2950 180 16.8 DTM 472 20190313 CAS PR 3 11.2 CAS CO 45 152 AMT B6 28 CLP 7722337 1 226 132 12 119932404007801 11 1 NM1 QC 1 JONES SALLY MI SJD11133 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190321 CAS CO 45 21 AMT B6 25 SVC AD D0220 25 14 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 117 128 DTM 472 20190321 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190321 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190321 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190321 CAS CO 45 24 AMT B6 49 CLP 7722337 1 179 108 12 119932404007801 11 1 NM1 QC 1 DOE SAM MI SJD99999 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 108 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 129 82 12 119932404007801 11 1 NM1 QC 1 DOE SUE MI SJD88888 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 82 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D1120 54 37 DTM 472 20190324 CAS CO 45 17 AMT B6 37 SVC AD D1208 29 20 DTM 472 20190324 CAS CO 45 9 AMT B6 20 CLP 7722337 1 221 144 12 119932404007801 11 1 NM1 QC 1 DOE DONNA MI SJD77777 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 144 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0330 92 62 DTM 472 20190324 CAS CO 45 30 AMT B6 62 SVC AD D1120 54 37 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 118 128 DTM 472 20190324 CAS CO 45 17 AMT B6 37 SVC AD D1208 29 20 DTM 472 20190324 CAS CO 45 9 AMT B6 20 | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_29 |
8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 118 128 DTM 472 20190324 CAS CO 45 17 AMT B6 37 SVC AD D1208 29 20 DTM 472 20190324 CAS CO 45 9 AMT B6 20 SE 183 35681 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 119 128 Example 3: Claim Specific Negotiated Discount ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 35681 BPR I 132 C CHK 20190331 TRN 1 12345 1512345678 REF EV CLEARINGHOUSE N1 PR DELTA DENTAL OF ABC N3 225 MAIN STREET N4 CENTERVILLE PA 17111 PER BL JANE DOE TE 9005555555 N1 PE BAN DDS LLC FI 999994703 LX 1 CLP 7722337 1 226 132 12 119932404007801 NM1 QC 1 DOE SALLY MI SJD11111 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 131 21 AMT B6 25 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 131 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190324 CAS CO 131 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 131 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 131 24 AMT B6 49 SE 35 35681 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 120 128 Example 4: Claim Adjustment Reason Code 45 ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 80.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PATACCT 1 400 80 MC CLAIMNUMBER 11 1 NM1 QC 1 DOE JOHN N MI ABC123456789 REF 1L 12345F DTM 050 20190209 PER CX G CUSTOMER SERVICE DEPARTMENT TE 8004074627 AMT AU 150 SVC HC 99213 150 80 1 DTM 472 20190101 CAS CO 45 70 AMT B6 80 SVC HC 85003 100 0 1 DTM 472 20190101 CAS CO 204 100 SVC HC 36415 150 0 1 DTM 472 20190101 CAS CO 97 150 SE 33 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 121 128 Example 5a: Line Service Tax impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 11.06 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PCN 1 36.20 11.06 12 CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 MOA N25 REF 1L 102345 REF EA 065789 DTM 050 20170113 AMT AU 36.20 SVC HC 99214 26.2 3.06 DTM 472 20170109 CAS CO 45 23.2 137 -.06 REF 6R B1 AMT B6 3 SVC HC 36415 10 8 DTM 472 20170109 CAS CO 45 2 REF 6R B2 AMT B6 8 SE 35 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 122 128 Example 5b: Line Service Bonuses impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 12.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PCN 1 25 12 10 12 CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 MOA N25 REF 1L 102345 REF EA 065789 DTM 050 20170113 AMT AU 25 SVC HC 99214 25 12 DTM 472 20170109 CAS CO 45 5 161 -2 CAS PR 3 10 REF 6R 123 AMT B6 20 SE 31 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 123 128 Example 5c: Line Service Penalty impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 8.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PCN 1 25 8 10 12 | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_30 |
1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PCN 1 25 8 10 12 CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 MOA N25 REF 1L 102345 REF EA 065789 DTM 050 20170113 AMT AU 25 SVC HC 99214 25 8 DTM 472 20170109 CAS CO 45 5 B4 2 CAS PR 3 10 REF 6R 123 AMT B6 20 SE 31 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 124 128 Example 6: Not Covered Not Authorized Inpatient Facility claim days ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 8000.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PATACCT 1 40000 8000 MC CLAIMNUMBER 11 1 CAS CO 197 2000 1 45 30000 NM1 QC 1 DOE JOHN N MI ABC123456789 REF 1L 12345F DTM 232 20190101 DTM 233 20190105 DTM 050 20190209 PER CX G CUSTOMER SERVICE DEPARTMENT TE 8004001212 AMT AU 38000 QTY CA 4 SE 27 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 125 128 Example 8a: Claim submitted with incorrect subscriber as patient and incorrect ID ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 120.03 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP 04777796TLC777122 1 155 120.03 13 8838888212 11 1 NM1 QC 1 MASTERS MARVIN L MI 80444444403 NM1 IL 1 CABLE MABEL MI 80444444403 NM1 74 1 MASTERS MARVIN C 80444444401 NM1 82 1 SHELTON MD BLAKE XX 1666666666 REF 1L 28 REF CE HSOAP-LAOA DTM 232 20191114 DTM 233 20181114 DTM 050 20181119 AMT AU 155 SVC HC 99393 155 120.03 1 DTM 472 20181114 CAS CO 45 34.97 REF LU 11 REF 6R 22261822 AMT B6 120.03 SE 34 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 126 128 Example 8b: Claim submitted with incorrect subscriber name and ID ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 35.06 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP 02333TLC222222 1 115 35.06 35 13 8333333214 11 1 NM1 QC 1 KEATON ALEX P MI 80000006006 NM1 IL 1 THOMAS JASON MI 80000006006 NM1 74 1 JEROME C 80000006001 NM1 82 1 BLOOD MD RED N XX 1888888886 REF 1L 28 REF CE OAPOS-LAOA DTM 232 20191113 DTM 233 20191113 DTM 050 20191119 AMT AU 115 SVC HC 99213 115 35.06 1 DTM 472 20191113 CAS CO 45 44.94 CAS PR 3 35 REF LU 11 REF 6R 22261389 AMT B6 70.06 SE 35 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 127 128 Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including X12, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation. Example 8c: Claim submitted with for subscriber missing the Middle initial ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 2415.25 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP 05444444TLC999999 1 3903 2415.25 13 8777777782 21 1 NM1 QC 1 GONZALES SAMMY MI 80455555502 NM1 IL 1 LAPLANTE FERN MI 80455555502 NM1 74 1 R NM1 82 1 GOOD MD ROBERT B XX 19999999987 REF 1L 28 REF CE OAPOS-LAOA DTM 232 20191101 DTM 233 20191101 DTM 050 20191114 AMT AU 3903 AMT F5 150 SVC HC 59400 3903 2415.25 1 DTM 472 20191101 CAS CO 45 1487.75 REF LU | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_31 |
80455555502 NM1 74 1 R NM1 82 1 GOOD MD ROBERT B XX 19999999987 REF 1L 28 REF CE OAPOS-LAOA DTM 232 20191101 DTM 233 20191101 DTM 050 20191114 AMT AU 3903 AMT F5 150 SVC HC 59400 3903 2415.25 1 DTM 472 20191101 CAS CO 45 1487.75 REF LU 21 REF 6R 22215592 AMT B6 2415.25 SE 35 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-paymentadvice-x221a1 01GRYB6DS30MGXWBPFZCM3695E 128 128 | /kaggle/input/edi-db/X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 611ccfce5bd3b56fdab044af957c271c | 611ccfce5bd3b56fdab044af957c271c_32 |
Stedi maintains this guide based on public documentation from Health Partner Plans. Contact Health Partner Plans for official EDI specifications. To report any errors in this guide, please contact us. X12 835 Health Care Claim Payment Advice (X221A1) X12 Release 5010 Revised February 22, 2024 Go to Stedi Network This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Payment Advice Transaction Set (835) for use within the context of the Electronic Data Interchange (EDI) environment. This transaction set can be used to make a payment, send an Explanation of Benefits (EOB) remittance advice, or make a payment and send an EOB remittance advice only from a health insurer to a health care provider either directly or via a financial institution. Delimiters Segment Element Component Repetition View the latest version of this implementation guide as an interactive webpage https: www.stedi.com app guides view health-partner-plans health-care-claim- paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K POWERED BY Build EDI implementation guides at stedi.com 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 1 82 Overview ISA - Interchange Control Header Max use 1 Required GS - Functional Group Header Max use 1 Required Heading ST 0100 Transaction Set Header Max use 1 Required BPR 0200 Financial Information Max use 1 Required TRN 0400 Reassociation Trace Number Max use 1 Required REF 0600 Receiver Identification Max use 1 Optional Payer Identification Loop N1 0800 Payer Identification Max use 1 Required N3 1000 Payer Address Max use 1 Required N4 1100 Payer City, State, ZIP Code Max use 1 Required PER 1300 Payers Claim Office Max use 1 Optional PER 1300 Technical Department Max use 1 Required PER 1300 Uniform Resource Locator (URL) Max use 1 Optional Payee Identification Loop N1 0800 Payee Identification Max use 1 Required N3 1000 Payee Address Max use 1 Optional N4 1100 Payee City, State, ZIP Code Max use 1 Optional REF 1200 Federal Taxpayer's Identification Number Max use 1 Optional REF 1200 Payee Identification Max use 1 Optional RDM 1400 Remittance Delivery Method Max use 1 Optional Detail Header Number Loop LX 0030 Header Number Max use 1 Required Claim Payment Information Loop CLP 0100 Claim Payment Information Max use 1 Required 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 2 82 CAS 0200 Claim Adjustment Max use 99 Optional NM1 0300 Other Insured Max use 1 Optional NM1 0300 Patient Name Max use 1 Required NM1 0300 Service Provider Name Max use 1 Optional DTM 0500 Claim Received Date Max use 1 Optional DTM 0500 Coverage Expiration Date Max use 1 Optional AMT 0620 Claim Supplemental Information Max use 13 Optional Service Payment Information Loop SVC 0700 Service Payment Information Max use 1 Required DTM 0800 Service Date Max use 2 Optional CAS 0900 Service Adjustment Max use 99 Optional REF 1000 Line Item Control Number Max use 1 Optional REF 1000 Rendering Provider Information Max use 10 Optional REF 1000 Service Identification Max use 8 Optional AMT 1100 Service Supplemental Amount Max use 9 Optional LQ 1300 Health Care Remark Codes Max use 99 Optional Summary PLB 0100 Provider Adjustment Max use 1 Optional SE 0200 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 3 82 ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange- related control segments Example ISA 00 00 XX XXXXXXXXXXXXXX X XX XXXXXXXXXXXXXXX 250130 0825 00501 00000000 0 X X Max use 1 Required ISA-01 I01 Authorization Information Qualifier Identifier (ID) Required Code identifying the type of information in the Authorization Information 00 No Authorization Information Present (No Meaningful Information in I02) ISA-02 I02 Authorization Information Min 10 Max 10 String (AN) Required Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01) ISA-03 I03 Security Information Qualifier Identifier (ID) Required Code identifying the type of information in the Security Information 00 No Security Information Present (No Meaningful Information in I04) ISA-04 I04 Security Information Min 10 Max 10 String (AN) Required This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03) ISA-05 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-06 I06 Interchange Sender ID Min 15 Max 15 String (AN) Required 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 4 82 Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element ISA-07 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-08 I07 Interchange Receiver ID Min 15 Max 15 String (AN) Required Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them ISA-09 I08 Interchange Date YYMMDD format Date (DT) Required Date of the interchange ISA-10 I09 Interchange Time HHMM format Time (TM) Required Time of the interchange ISA-11 I65 Repetition Separator Min 1 Max 1 String (AN) Required Type is not applicable; the repetition separator is a | /kaggle/input/edi-db/Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 654752ca5715dec30fa59b0a1628633b | 654752ca5715dec30fa59b0a1628633b_0 |
route data to them ISA-09 I08 Interchange Date YYMMDD format Date (DT) Required Date of the interchange ISA-10 I09 Interchange Time HHMM format Time (TM) Required Time of the interchange ISA-11 I65 Repetition Separator Min 1 Max 1 String (AN) Required Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator Repetition Separator ISA-12 I11 Interchange Control Version Number Identifier (ID) Required Code specifying the version number of the interchange control segments 00501 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003 ISA-13 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender ISA-14 I13 Acknowledgment Requested Min 1 Max 1 Identifier (ID) Required 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 5 82 Code indicating sender's request for an interchange acknowledgment 0 No Interchange Acknowledgment Requested 1 Interchange Acknowledgment Requested (TA1) ISA-15 I14 Interchange Usage Indicator Min 1 Max 1 Identifier (ID) Required Code indicating whether data enclosed by this interchange envelope is test, production or information I Information P Production Data T Test Data ISA-16 I15 Component Element Separator Min 1 Max 1 String (AN) Required Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator Component Element Separator 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 6 82 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GS HP XXXX XX 20250130 1226 000 X 005010X221A1 Max use 1 Required GS-01 479 Functional Identifier Code Identifier (ID) Required Code identifying a group of application related transaction sets HP Health Care Claim Payment Advice (835) GS-02 142 Application Sender's Code Min 2 Max 15 String (AN) Required Code identifying party sending transmission; codes agreed to by trading partners GS-03 124 Application Receiver's Code Min 2 Max 15 String (AN) Required Code identifying party receiving transmission; codes agreed to by trading partners GS-04 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year GS-05 337 Time HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time (TM) Required Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H hours (00-23), M minutes (00-59), S integer seconds (00-59) and DD decimal seconds; decimal seconds are expressed as follows: D tenths (0-9) and DD hundredths (00-99) GS-06 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480 T Transportation Data Coordinating Committee (TDCC) 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 7 82 X Accredited Standards Committee X12 GS-08 480 Version Release Industry Identifier Code String (AN) Required Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed 005010X221A1 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 8 82 Heading ST 0100 Heading ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST 835 0001 Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) Required Code uniquely identifying a Transaction Set The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set). Usage notes The only valid value within this transaction set for ST01 is 835. 835 Health Care Claim Payment Advice ST-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Start with a number, for example 0001, and increment from there. This number must be unique within a specific group and interchange, but it can be repeated in other groups and interchanges. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 9 82 BPR 0200 Heading BPR Financial Information To indicate the beginning of a Payment Order Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and or information from payer to payee to occur Usage notes Use the BPR to address a single payment to a single payee. A payee may represent a single provider, a provider group, or multiple providers in a chain. The BPR contains mandatory information, even when it is not being used to move funds electronically. Example BPR I 0000000000000 C CHK 20250130 Max use 1 Required | /kaggle/input/edi-db/Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 654752ca5715dec30fa59b0a1628633b | 654752ca5715dec30fa59b0a1628633b_1 |
a single payment to a single payee. A payee may represent a single provider, a provider group, or multiple providers in a chain. The BPR contains mandatory information, even when it is not being used to move funds electronically. Example BPR I 0000000000000 C CHK 20250130 Max use 1 Required BPR-01 305 Transaction Handling Code Identifier (ID) Required Code designating the action to be taken by all parties I Remittance Information Only Use this code to indicate to the payee that the remittance detail is moving separately from the payment. BPR-02 782 Total Actual Provider Payment Amount Decimal number (R) Required Min 1 Max 15 Monetary amount BPR02 specifies the payment amount. Usage notes Use BPR02 for the total payment amount for this 835. The total payment amount for this 835 cannot exceed eleven characters, including decimals (99999999.99). Although the value can be zero, the 835 cannot be issued for less than zero dollars. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). BPR-03 478 Credit or Debit Flag Code Identifier (ID) Required Code indicating whether amount is a credit or debit C Credit Use this code to indicate a credit to the provider's account and a debit to the payer's account, initiated by the payer. In the case of an EFT, no additional action is required of the provider. Also use this code when a check is issued for the payment. BPR-04 591 Payment Method Code Identifier (ID) Required Code identifying the method for the movement of payment instructions 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 10 82 CHK Check Use this code to indicate that a check has been issued for payment. BPR-16 373 Check Issue or EFT Effective Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year BPR16 is the date the originating company intends for the transaction to be settled (i.e., Payment Effective Date). Usage notes Use this for the effective entry date. If BPR04 is ACH, this is the date that the money moves from the payer and is available to the payee. If BPR04 is CHK, this is the check issuance date. If BPR04 is FWT, this is the date that the payer anticipates the money to move. As long as the effective date is a business day, this is the settlement date. If BPR04 is NON', enter the date of the 835. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 11 82 TRN 0400 Heading TRN Reassociation Trace Number To uniquely identify a transaction to an application Usage notes This segment's purpose is to uniquely identify this transaction set and to aid in reassociating payments and remittances that have been separated. Example TRN 1 XX XXXXXXXXXX Max use 1 Required TRN-01 481 Trace Type Code Identifier (ID) Required Code identifying which transaction is being referenced 1 Current Transaction Trace Numbers TRN-02 127 Check or EFT Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TRN02 provides unique identification for the transaction. Usage notes This number must be unique within the sender receiver relationship. The number is assigned by the sender. If payment is made by check, this must be the check number. If payment is made by EFT, this must be the EFT reference number. If this is a non- payment 835, this must be a unique remittance advice identification number. See 1.10.2.3, Reassociation of Dollars and Data, for additional information. Check Number TRN-03 509 Payer Identifier Min 10 Max 10 String (AN) Required A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification. TRN03 identifies an organization. Usage notes This must be a 1 followed by the payer's EIN (or TIN). 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 12 82 REF 0600 Heading REF Receiver Identification To specify identifying information Usage notes This is the business identification information for the transaction receiver. This may be different than the EDI address or identifier of the receiver. This is the initial receiver of the transaction. This information must not be updated if the transaction is routed through multiple intermediaries, such as clearinghouses, before reaching the payee. Required when the receiver of the transaction is other than the payee (e.g., a clearinghouse or billing service). If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example REF EV XX Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EV Receiver Identification Number REF-02 127 Receiver Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Receiver Identification Number 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 13 82 1000A Payer Identification Loop Max 1 Required Variants (all may be used) Payee Identification Loop N1 0800 Heading Payer Identification Loop N1 Payer Identification To identify a party by type of organization, name, and code Usage notes Use this N1 loop to provide the name address information for the payer. The payer's secondary identifying reference number is provided in N104, if necessary. Example N1 PR Health Partners of Philadelphia Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer N1-02 93 Payer Name String (AN) Required Free-form name Health Partners of Philadelphia 1 29 25, 8:52 PM | /kaggle/input/edi-db/Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 654752ca5715dec30fa59b0a1628633b | 654752ca5715dec30fa59b0a1628633b_2 |
N1 PR Health Partners of Philadelphia Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer N1-02 93 Payer Name String (AN) Required Free-form name Health Partners of Philadelphia 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 14 82 N3 1000 Heading Payer Identification Loop N3 Payer Address To specify the location of the named party Example N3 901 Market St Suite 500 Max use 1 Required N3-01 166 Payer Address Line String (AN) Required Address information 901 Market St N3-02 166 Payer Address Line String (AN) Optional Address information Suite 500 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 15 82 N4 1100 Heading Payer Identification Loop N4 Payer City, State, ZIP Code To specify the geographic place of the named party Example N4 Philadelphia PA 19107 XXX Only one of Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Payer City Name String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. Philadelphia N4-02 156 Payer State Code Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. PA N4-03 116 Payer Postal Zone or ZIP Code Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) 19107 N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 16 82 Use the country subdivision codes from Part 2 of ISO 3166. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 17 82 PER 1300 Heading Payer Identification Loop PER Payers Claim Office To identify a person or office to whom administrative communications should be directed Usage notes When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800) 555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number. Required when there is a business contact area that would apply to this remittance and all the claims. If not required by this implementation guide, do not send. Example PER CX Claim Department TE 2159914350 TE XXX EX X X Variants (all may be used) PER Technical Department PER Uniform Resource Locator (URL) If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required If either Communication Number Qualifier (PER-05) or Payer Contact Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Payer Contact Name String (AN) Optional Free-form name Usage notes Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). Claim Department PER-03 365 Communication Number Qualifier Identifier (ID) Optional 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 18 82 Code identifying the type of communication number TE Telephone PER-04 364 Payer Contact Communication Number String (AN) Optional Complete communications number including country or area code when applicable 2159914350 PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 19 82 PER 1300 Heading Payer Identification Loop PER Technical Department To identify a person or office to whom administrative communications should be directed Usage notes Required to report technical contact information for this remittance advice. Example PER BL EDI Support TE 2159914290 EM EDI HEALTHPAR T.COM FX XXXX Variants (all may be used) PER Payers Claim Office PER Uniform Resource Locator (URL) If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required If either Communication Number Qualifier (PER-05) or Payer Technical Contact Communication Number (PER-06) is present, then the other is required If either | /kaggle/input/edi-db/Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 654752ca5715dec30fa59b0a1628633b | 654752ca5715dec30fa59b0a1628633b_3 |
PER Payers Claim Office PER Uniform Resource Locator (URL) If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required If either Communication Number Qualifier (PER-05) or Payer Technical Contact Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required Max use 1 Required PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named BL Technical Department PER-02 93 Payer Technical Contact Name String (AN) Optional Free-form name Usage notes Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). EDI Support PER-03 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number TE Telephone Recommended PER-04 364 Payer Contact Communication Number String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 20 82 2159914290 PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail PER-06 364 Payer Technical Contact Communication Number String (AN) Optional Complete communications number including country or area code when applicable EDI HEALTHPART.COM PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is theextension for the preceding communicationscontact number. FX Facsimile UR Uniform Resource Locator (URL) PER-08 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 21 82 1000A Payer Identification Loop end PER 1300 Heading Payer Identification Loop PER Uniform Resource Locator (URL) To identify a person or office to whom administrative communications should be directed Usage notes Required when any 2110 loop Healthcare Policy REF Segment is used. If not required by this implementation guide, do not send. This is a direct link to the policy location of the un-secure website. Example PER IC UR www.healthpart.com Variants (all may be used) PER Payers Claim Office PER Technical Department Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number UR Uniform Resource Locator (URL) PER-04 364 Communication Number String (AN) Required Complete communications number including country or area code when applicable Usage notes This is the payer's WEB site URL where providers can find policy and other related information. www.healthpart.com 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 22 82 1000B Payee Identification Loop Max 1 Required Variants (all may be used) Payer Identification Loop N1 0800 Heading Payee Identification Loop N1 Payee Identification To identify a party by type of organization, name, and code Usage notes Use this N1 loop to provide the name address information of the payee. The identifying reference number is provided in N104. Example N1 PE XXX XX XXXX Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PE Payee N1-02 93 Payee Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Required if provider is not mandated by NPI. For individual providers as payees, use this qualifier to represent the Social Security Number. XX Centers for Medicare and Medicaid Services National Provider Identifier This is REQUIRED when the National Provider Identifier is mandated for use and the payee is a covered health care provider under the mandate. N1-04 67 Payee Identification Code Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 23 82 This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 24 82 N3 1000 Heading Payee Identification Loop N3 Payee Address To specify the location of the named party Usage notes Required when the sender needs to communicate the payee address to a transaction receiver, e.g., a VAN or a clearinghouse. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Situational (when needed to inform Receiver of Payee Address) Example N3 XXX XXXXXX Max use 1 Optional N3-01 166 Payee Address Line Min 1 Max 55 String (AN) Required Address information Usage notes Payee Address Information provided to Health Partners N3-02 166 Payee Address Line Min 1 Max 55 String (AN) Optional Address information Usage notes Payee Address Information, if second line needed 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 25 82 N4 1100 Heading Payee Identification Loop N4 Payee City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the sender needs to communicate the payee address to a transaction receiver, e.g., a | /kaggle/input/edi-db/Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 654752ca5715dec30fa59b0a1628633b | 654752ca5715dec30fa59b0a1628633b_4 |
Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 25 82 N4 1100 Heading Payee Identification Loop N4 Payee City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the sender needs to communicate the payee address to a transaction receiver, e.g., a VAN or a clearinghouse. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Situational (when needed to inform Receiver) Example N4 XXXXXX XX XXXXXXXX XXX Only one of Payee State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Payee City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. Usage notes Payee City Name provided N4-02 156 Payee State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. Usage notes Payee State Name provided N4-03 116 Payee Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes Payee Zip Code provided N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 26 82 Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 27 82 REF 1200 Heading Payee Identification Loop REF Federal Taxpayer's Identification Number To specify identifying information Usage notes Required when identification of the payee is dependent upon an identification number beyond that supplied in the N1 segment. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Situational (When additional identification is needed) Example REF TJ XXXXXX Variants (all may be used) REF Payee Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification TJ Federal Taxpayer's Identification Number REF-02 127 Additional Payee Identifier Min 1 Max 30 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Federal Taxpayer Identification Number 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 28 82 REF 1200 Heading Payee Identification Loop REF Payee Identification To specify identifying information Usage notes Required when identification of the payee is dependent upon an identification number beyond that supplied in the N1 segment. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Situational (When additional identification is needed) Example REF PQ X Variants (all may be used) REF Federal Taxpayer's Identification Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PQ Payee Identification REF-02 127 Additional Payee Identifier Min 1 Max 30 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Health Partners Legacy Number 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 29 82 RDM 1400 Heading Payee Identification Loop RDM Remittance Delivery Method To identify remittance delivery when remittance is separate from payment Usage notes Required when BPR01 U or X; and the remittance is to be sent separately from the payment. The payer is responsible to provide the bank with the instructions on how to deliver the remittance information, if not required by this implementation guide, do not send. Payer should coordinate this process with their Originating Depository Financial Institution (ODFI). Example RDM BM XXX XXXX Max use 1 Optional RDM-01 756 Report Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent BM By Mail When used, RDM02 must be used. When BM is used, the remittance information will be mailed to the payee at the address identified in this 1000B loop. EM E-Mail Use with encrypted e-mail. FT File Transfer Use with FTP communications. OL On-Line Use with secured hosted or other electronic delivery. RDM-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name RDM02 is used to contain the name of a third party processor if needed, who would be the first recipient of the remittance. Usage notes When BM is used, the remittance information will be mailed to the attention of this person at the payee's address identified in this 1000B loop. RDM-03 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable RDM03 contains the operative communication number for the delivery method specified in RDM01 (i.e. fax phone number and mail address). Usage notes 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 30 82 1000B Payee Identification Loop end Heading end Contains URL web address or e-mail address. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 31 82 Detail 2000 Header Number Loop Max 1 Optional LX 0030 | /kaggle/input/edi-db/Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 654752ca5715dec30fa59b0a1628633b | 654752ca5715dec30fa59b0a1628633b_5 |
Loop end Heading end Contains URL web address or e-mail address. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 31 82 Detail 2000 Header Number Loop Max 1 Optional LX 0030 Detail Header Number Loop LX Header Number To reference a line number in a transaction set Usage notes Required when claim service information is being provided in the transaction. If not required by this implementation guide, do not send. The purpose of LX01 is to provide an identification of a particular grouping of claims for sorting purposes. In the event that claim service information must be sorted, the LX segment must precede each series of claim level and service level segments. This number is intended to be unique within each transaction. Example LX 00000 Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 32 82 2100 Claim Payment Information Loop Max 1 Required CLP 0100 Detail Header Number Loop Claim Payment Information Loop CLP Claim Payment Information To supply information common to all services of a claim Usage notes For CLP segment occurrence limitations, see section 1.3.2, Other Usage Limitations. Example CLP XX 2 0000000 000000000 000 HM XXX XX X XX 00 0 Max use 1 Required CLP-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment Usage notes Use this number for the patient control number assigned by the provider. If the patient control number is not present on the incoming claim, enter a single zero. The value in CLP01 must be identical to any value received as a Claim Submitter's Identifier on the original claim (CLM01 of the ANSI ASC X12 837, if applicable). This data element is the primary key for posting the remittance information into the provider's database. In the case of pharmacy claims, this is the prescription reference number (field 402-02 in the NCPDP 5.1 format). CLP-02 1029 Claim Status Code Identifier (ID) Required Code identifying the status of an entire claim as assigned by the payor, claim review organization or repricing organization Usage notes To determine the full claim status reference Claim adjustment reason codes in the CAS segment in conjunction with this claim status code. Claim Status. See page 124 of HIPAA TR3 for valid codes 1 Processed as Primary Use this code if the claim was adjudicated by the current payer as primary regardless of whether any part of the claim was paid. 2 Processed as Secondary Use this code if the claim was adjudicated by the current payer as secondary regardless of whether any part of the claim was paid. 3 Processed as Tertiary Use this code if the claim was adjudicated by the current payer as tertiary (or subsequent) regardless of whether any part of the claim was paid. 4 Denied 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 33 82 Usage of this code would apply if the Patient Subscriber is not recognized, and the claim was not forwarded to another payer. 19 Processed as Primary, Forwarded to Additional Payer(s) When this code is used, the Crossover Carrier Name NM1 segment is required. 20 Processed as Secondary, Forwarded to Additional Payer(s) When this code is used, the Crossover Carrier Name NM1 segment is required. 21 Processed as Tertiary, Forwarded to Additional Payer(s) When this code is used, the Crossover Carrier Name NM1 segment is required. 22 Reversal of Previous Payment See section 1.10.2.8 for usage information. 23 Not Our Claim, Forwarded to Additional Payer(s) Usage of this code would apply if the patient subscriber is not recognized, the claim was not adjudicated by the payer, but other payers are known and the claim has been forwarded to another payer. When this code is used, the Crossover Carrier Name NM1 segment is required. 25 Predetermination Pricing Only - No Payment CLP-03 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLP03 is the amount of submitted charges this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. Use this monetary amount for the submitted charges for this claim. The amount can be positive, zero or negative. An example of a situation with a negative charge is a reversal claim. See section 1.10.2.8 for additional information. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CLP-04 782 Claim Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLP04 is the amount paid this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. See section 1.10.2.9 for information about interest considerations. Use this monetary amount for the amount paid for this claim. It can be positive, zero or negative, but the value in BPR02 may not be negative. CLP-05 782 Patient Responsibility Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CLP05 is the patient responsibility amount. Usage notes 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 34 82 Amounts in CLP05 must have supporting adjustments reflected in CAS segments at the 2100 (CLP) or 2110 (SVC) loop level with a Claim Adjustment Group (CAS01) code of PR (Patient Responsibility). Use this monetary amount for the payer's statement of the patient responsibility amount for this claim, which can include such items as deductible, non-covered services, co-pay and co-insurance. This is not used for reversals. See section 1.10.2.8, Reversals and Corrections, for additional information. CLP-06 1032 | /kaggle/input/edi-db/Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 654752ca5715dec30fa59b0a1628633b | 654752ca5715dec30fa59b0a1628633b_6 |
code of PR (Patient Responsibility). Use this monetary amount for the payer's statement of the patient responsibility amount for this claim, which can include such items as deductible, non-covered services, co-pay and co-insurance. This is not used for reversals. See section 1.10.2.8, Reversals and Corrections, for additional information. CLP-06 1032 Claim Filing Indicator Code Identifier (ID) Required Code identifying type of claim Usage notes For many providers to electronically post the 835 remittance data to their patient accounting systems without human intervention, a unique, provider-specific insurance plan code is needed. This code allows the provider to separately identify and manage the different product lines or contractual arrangements between the payer and the provider. Because most payers maintain the same Originating Company Identifier in the TRN03 or BPR10 for all product lines or contractual relationships, the CLP06 is used by the provider as a table pointer in combination with the TRN03 or BPR10 to identify the unique, provider-specific insurance plan code needed to post the payment without human intervention. The value should mirror the value received in the original claim (2- 005 SBR09 of the 837), if applicable, or provide the value as assigned or edited by the payer. For example the BL from the SBR09 in the 837 would be returned as 12, 13, 15, in the 835 when more details are known. The 837 SBR09 code CI (Commercial Insurance) is generic, if through adjudication the specific type of plan is obtained a more specific code must be returned in the 835. The 837 and 835 transaction code lists for this element are not identical by design. There are some business differences between the two transactions. When a code from the 837 is not available in the 835 another valid code from the 835 must be assigned by the payer. HM Health Maintenance Organization CLP-07 127 Payer Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CLP07 is the payer's internal control number. Usage notes Use this number for the payer's internal control number. This number must apply to the entire claim. CLP-08 1331 Facility Type Code Min 1 Max 2 String (AN) Optional Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. Usage notes Since professional or dental claims can have different place of service codes for services within a single claim, default to the place of service of the first service line 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 35 82 when the service lines are not all for the same place of service. This number was received in CLM05-1 of the 837 claim. CLP-09 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Optional Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type Usage notes This number was received in CLM05-3 of the 837 Claim. CLP-11 1354 Diagnosis Related Group (DRG) Code Min 1 Max 4 Identifier (ID) Optional Code indicating a patient's diagnosis group based on a patient's illness, diseases, and medical problems Usage notes Code Source 229. Institutional claims only. CLP-12 380 Diagnosis Related Group (DRG) Weight Decimal number (R) Optional Min 1 Max 15 Numeric value of quantity CLP12 is the diagnosis-related group (DRG) weight. Usage notes This is the adjudicated DRG Weight. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 36 82 CAS 0200 Detail Header Number Loop Claim Payment Information Loop CAS Claim Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Payers must use this CAS segment to report claim level adjustments that cause the amount paid to differ from the amount originally charged. See 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. See the SVC TR3 Note 1 for details about per diem adjustments. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment must be the first non-zero adjustment and is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Required when dollar amounts and or quantities are being adjusted at the claim level. If not required by this implementation guide, do not send. Example CAS PI XXX 00000000000000 00000000 Max use 99 Optional CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer payee contractual agreement or a regulatory requirement resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PI Payor Initiated Reductions Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the | /kaggle/input/edi-db/Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 654752ca5715dec30fa59b0a1628633b | 654752ca5715dec30fa59b0a1628633b_7 |
Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PI Payor Initiated Reductions Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments). PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 37 82 Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the claim level for the claim adjustment group code reported in CAS01. Code Source 139: Claim Adjustment Reason Code CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. Claim Level Adjustment Amount CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes See section 1.10.2.4.1 for additional information. A positive value decreases the covered days, and a negative number increases the covered days. Provided only when unit quantity is being adjusted 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 38 82 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Other Insured To supply the full name of an individual or organizational entity Usage notes This is the name and ID number of the other subscriber when a corrected priority payer has been identified. When used, either the name or ID must be supplied. Required when a corrected priority payer has been identified in another NM1 segment AND the name or ID of the other subscriber is known. If not required by this implementation guide, do not send. Example NM1 GB 2 X XX XXXX XXXXXX FI XXXXX Variants (all may be used) NM1 Patient Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Other Subscriber Identifier (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual GB Other Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Subscriber Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name Usage notes At least one of NM103 or NM109 must be present. NM1-04 1036 Other Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 39 82 Individual middle name or initial Usage notes When only one character is present this is assumed to be the middle initial. NM1-07 1039 Other Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Not Used when NM102 1. II Standard Unique Health Identifier for each Individual in the United States Use this code if mandated in a final Federal Rule. MI Member Identification Number Use this code when supplying the number used for identification of the subscriber in NM109. NM1-09 67 Other Subscriber Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes At least one of NM103 or NM109 must be present. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 40 82 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Patient Name To supply the full name of an individual or organizational entity Usage notes Provide the patient's identification number in NM109. This segment must provide the information from the original claim. For example, when the claim is submitted as an ASC X12 837 transaction, this is the 2010CA loop NM1 Patient Name Segment unless not present on the original claim, then it is the 2010BA loop NM1 Subscriber name segment. The Corrected Patient Insured Name NM1 segment identifies the adjudicated Insured Name and ID information if different than what was submitted on the claim. Example NM1 QC 1 XX XXXXXX XX MI XXXXX Variants (all may be used) NM1 Other Insured NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Patient Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual QC Patient NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Patient Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Patient First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Patient Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 41 82 Usage notes If this data element | /kaggle/input/edi-db/Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 654752ca5715dec30fa59b0a1628633b | 654752ca5715dec30fa59b0a1628633b_8 |
Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 41 82 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) MI Member Identification Number NM1-09 67 Patient Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 42 82 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Service Provider Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the rendering provider. An identification number is provided in NM109. This information is provided to facilitate identification of the claim within a payee's system. Other providers (e.g., Referring provider, supervising provider) related to the claim but not directly related to the payment are not supported and are not necessary for claim identification. Required when the rendering provider is different from the payee. If not required by this implementation guide, do not send. Example NM1 82 1 XX X XX XXX Variants (all may be used) NM1 Other Insured NM1 Patient Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Name Last or Organization Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Name First Min 1 Max 35 String (AN) Optional Individual first name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 43 82 XX Centers for Medicare and Medicaid Services National Provider Identifier Required value if the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate. Otherwise, one of the other listed codes may be used. NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes National Provider Identifier Number Provided 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 44 82 DTM 0500 Detail Header Number Loop Claim Payment Information Loop DTM Claim Received Date To specify pertinent dates and times Usage notes Required whenever state or federal regulations or the provider contract mandate interest payment or prompt payment discounts based upon the receipt date of the claim by the payer. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example DTM 050 20250130 Variants (all may be used) DTM Coverage Expiration Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the date that the claim was received by the payer. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 45 82 DTM 0500 Detail Header Number Loop Claim Payment Information Loop DTM Coverage Expiration Date To specify pertinent dates and times Usage notes Required when payment is denied because of the expiration of coverage. If not required by this implementation guide, do not send. Situational (Required due to expiration of coverage) Example DTM 036 20250130 Variants (all may be used) DTM Claim Received Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 036 Expiration DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the expiration date of the patient's coverage. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 46 82 AMT 0620 Detail Header Number Loop Claim Payment Information Loop AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send receive one AMT for each applicable non-zero value. Do not report any zero values. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMT D8 000 Max use 13 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount D8 Discount Amount Prompt Pay Discount Amount See section 1.10.2.9 for additional information. I Interest See section 1.10.2.9 for additional information. T Tax AMT-02 782 Claim Supplemental Information Amount Decimal number (R) Required Min 1 Max 15 Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 47 82 2110 Service | /kaggle/input/edi-db/Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 654752ca5715dec30fa59b0a1628633b | 654752ca5715dec30fa59b0a1628633b_9 |
implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 47 82 2110 Service Payment Information Loop Max 999 Optional SVC 0700 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop SVC Service Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO78 25 ). See section 1.10.2.4.1 for additional information. See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information. Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send. Example SVC NU XXX XX XX XX XX 00000000 00000000000000 0 00 ER X 000000000 Max use 1 Required SVC-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132). Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7. See HIPAA 835 Technical Report Type 3, pg. 187-188 for supported codes AD American Dental Association Codes ER Jurisdiction Specific Procedure and Supply Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 48 82 HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. N4 National Drug Code in 5-4-2 Format N6 National Health Related Item Code in 4-6 Format This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names National Health Related Item Code in 4-6 Format Codes as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. NU National Uniform Billing Committee (NUBC) UB92 Codes UI U.P.C. Consumer Package Code (1-5-5) This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names U.P.C. Consumer Package Code (1-5-5) Codes as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. WK Advanced Billing Concepts (ABC) Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used in transactions covered under HIPAA by parties registered in the pilot project and their trading partners. C003-02 234 Adjudicated Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 49 82 C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. SVC-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC02 is the submitted service charge. Usage notes Use this monetary amount for the submitted service charge amount. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. SVC-03 782 Line Item Provider Payment Amount Min 1 Max 15 | /kaggle/input/edi-db/Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 654752ca5715dec30fa59b0a1628633b | 654752ca5715dec30fa59b0a1628633b_10 |
the submitted service charge amount. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. SVC-03 782 Line Item Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC03 is the amount paid this service. Usage notes Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. See 1.10.2.1, Balancing, for additional information. SVC-05 380 Units of Service Paid Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC05 is the paid units of service. Usage notes If not present, the value is assumed to be one. SVC-06 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC06 is the original submitted medical procedure. Usage notes Max use 1 Optional 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 50 82 Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send. C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7. Provided if procedure code in SVC01 is different from procedure code submitted; see pg. 191 of the HIPAA Technical Report Type 3 AD American Dental Association Codes ER Jurisdiction Specific Procedure and Supply Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes WK Advanced Billing Concepts (ABC) Codes This qualifier can only be used in transactions covere under HIPAA by parties registered in the pilot project and their trading partners. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. SVC-07 380 Original Units of Service Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC07 is the original submitted units of service. Usage notes 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 51 82 Only provided when paid unit is different from submitted units 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 52 82 DTM 0800 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop DTM Service Date To specify pertinent dates and times Usage notes Dates at the service line level apply only to the service line where they appear. If used for inpatient claims and no service date was provided on the claim then report the through date from the claim level. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. Required when claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. For retail pharmacy claims, the service date is equivalent to the prescription filled date. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM 151 20250130 Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 150 Service Period Start This qualifier is required for reporting the beginning of multi-day services. If not required by this implementation guide, do not send. 151 Service Period End This qualifier is required for reporting the end of multi-day services. If not required by this implementation guide, do not send. 472 Service This qualifier is required to indicate a single day service. If not required by this implementation guide, do not send. DTM-02 373 Service Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 53 82 CAS 0900 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop CAS Service Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes An example of this level of CAS is the reduction for the part | /kaggle/input/edi-db/Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 654752ca5715dec30fa59b0a1628633b | 654752ca5715dec30fa59b0a1628633b_11 |
Loop Claim Payment Information Loop Service Payment Information Loop CAS Service Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes An example of this level of CAS is the reduction for the part of the service charge that exceeds the usual and customary charge for the service. See sections 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02). If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Situational (to account for difference in amount paid for this service) Example CAS CO XXXX 0000000 00000000000000 Max use 99 Optional CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer payee agreement or a regulatory requirement has resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PI Payor Initiated Reductions Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments). PR Patient Responsibility 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 54 82 CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01. Code Source 139: Claim Adjustment Reason Code CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03 and CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes A positive number decreases paid units, and a negative value increases paid units. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 55 82 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Line Item Control Number To specify identifying information Usage notes This is the Line Item Control Number submitted in the 837, which is utilized by the provider for tracking purposes. See section 1.10.2.11 and 1.10.2.14.1 for additional information on usage with split claims or services. Note - the value in REF02 can include alpha characters. Required when a Line Item Control Number was received on the original claim or when claim or service line splitting has occurred. If not required by this implementation guide, do not send. Example REF 6R XX Variants (all may be used) REF Rendering Provider Information REF Service Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 56 82 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Rendering Provider Information To specify identifying information Usage notes Required when the rendering provider for this service is different than the rendering provider applicable at the claim level. If not required by this implementation guide, do not send. Example REF TJ XXXX Variants (all may be used) REF Line Item Control Number REF Service Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification HPI Centers for Medicare and Medicaid Services National Provider Identifier This qualifier is REQUIRED when the National Provider Identifier is mandated for use and the provider is a covered health care provider under that mandate. TJ Federal Taxpayer's Identification Number REF-02 127 Rendering Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides | /kaggle/input/edi-db/Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 654752ca5715dec30fa59b0a1628633b | 654752ca5715dec30fa59b0a1628633b_12 |
Rendering Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 57 82 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Service Identification To specify identifying information Usage notes Required when related service specific reference identifiers were used in the process of adjudicating this service. If not required by this implementation guide, do not send. Example REF APC XX Variants (all may be used) REF Line Item Control Number REF Rendering Provider Information Max use 8 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1S Ambulatory Patient Group (APG) Number APC Ambulatory Payment Classification BB Authorization Number E9 Attachment Code G1 Prior Authorization Number G3 Predetermination of Benefits Identification Number LU Location Number This is the Payer's identification for the provider location. This is REQUIRED when the specific site of service affected the payment of the claim. RB Rate code number Rate Code Number reflects Ambulatory Surgical Center (ASC) rate for Medicare, either 0, 50, 100 or 150. REF-02 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 58 82 AMT 1100 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop AMT Service Supplemental Amount To indicate the total monetary amount Usage notes This segment is used to convey information only. It is not part of the financial balancing of the 835. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMT ZK 00000000000 Max use 9 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount B6 Allowed - Actual Allowed amount is the amount the payer deems payable prior to considering patient responsibility. KH Deduction Amount Late Filing Reduction T Tax T2 Total Claim Before Taxes Use this monetary amount for the service charge before taxes. This is only used when there is an applicable tax amount on this service. ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 AMT-02 782 Service Supplemental Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. Corresponding Amount (Service Line Allowed Amount) 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 59 82 2110 Service Payment Information Loop end 2100 Claim Payment Information Loop end 2000 Header Number Loop end Detail end LQ 1300 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop LQ Health Care Remark Codes To identify standard industry codes Usage notes Use this segment to provide informational remarks only. This segment has no impact on the actual payment. Changes in claim payment amounts are provided in the CAS segments. Required when remark codes or NCPDP Reject Payment codes are necessary for the provider to fully understand the adjudication message for a given service line. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example LQ HE XXX Max use 99 Optional LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list HE Claim Payment Remark Codes LQ-02 1271 Remark Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 60 82 Summary PLB 0100 Summary PLB Provider Adjustment To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service Usage notes These adjustments can either decrease the payment (a positive number) or increase the payment (a negative number). Zero dollar adjustments are not allowed. Some examples of PLB adjustments are a Periodic Interim Payment (loans and loan repayment) or a capitation payment. Multiple adjustments can be placed in one PLB segment, grouped by the provider identified in PLB01 and the period identified in PLB02. Although the PLB reference numbers are not standardized, refer to 1.10.2.9 (Interest and Prompt Payment Discounts), 1.10.2.10 (Capitation and Related Payments or Adjustments), 1.10.2.12 (Balance Forward Processing), 1.10.2.16 (Post Payment Recovery) and 1.10.2.17 (Claim Overpayment Recovery) for code suggestions and usage guidelines. The codes and notations under PLB03 and its components apply equally to PLB05, 07, 09, 11 and 13. Required when reporting adjustments to the actual payment that are NOT specific to a particular claim or service. If not required by this implementation guide, do not send. Example PLB XXXXX 20250130 PI 00000 Max use 1 Optional PLB-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB01 is the provider number assigned by the payer. Usage notes When the National Provider Identifier (NPI) is mandated and the provider is a covered health care provider under that mandate, this must be the NPI assigned to the provider. Until the NPI | /kaggle/input/edi-db/Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 654752ca5715dec30fa59b0a1628633b | 654752ca5715dec30fa59b0a1628633b_13 |
as specified by the Reference Identification Qualifier PLB01 is the provider number assigned by the payer. Usage notes When the National Provider Identifier (NPI) is mandated and the provider is a covered health care provider under that mandate, this must be the NPI assigned to the provider. Until the NPI is mandated, this is the provider identifier as assigned by the payer. PLB-02 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year PLB02 is the last day of the provider's fiscal year. Usage notes 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 61 82 This is the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known by the payer, use December 31st of the current year. PLB-03 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB03 is the adjustment information as defined by the payer. Max use 1 Required C042-01 426 Adjustment Reason Code Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment Usage notes Refer to HIPAA Technical Report Type pg. 219-222 for supported Code Values 50 Late Charge This is the Late Claim Filing Penalty or Medicare Late Cost Report Penalty. 51 Interest Penalty Charge This is the interest assessment for late filing. 72 Authorized Return This is the provider refund adjustment. This adjustment acknowledges a refund received from a provider for previous overpayment. PLB03-2 must always contain an identifying reference number when the value is used. PLB04 must contain a negative value. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. 90 Early Payment Allowance AH Origination Fee This is the claim transmission fee. This is used for transmission fees that are not specific to or dependent upon individual claims. AM Applied to Borrower's Account See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. Use this code to identify the loan repayment amount. This is capitation specific. AP Acceleration of Benefits This is the accelerated payment amount or withholding. Withholding or payment identification is indicated by the sign of the amount in PLB04. A positive value represents a withholding. A negative value represents a payment. B2 Rebate This adjustment code applies when a provider has remitted an overpayment to a health plan in excess of the amount requested by the health plan. The amount accepted by the health plan is reported using code 72 (Authorized Return) and offset by the amount with code WO (Overpayment Recovery). The excess returned by the provider is reported as a negative amount using code B2, returning the excess funds to the provider. B3 Recovery Allowance This represents the check received from the provider for overpayments generated by payments from other payers. This code differs from the provider refund adjustment identified with code 72. This adjustment must always be offset by some other PLB 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 62 82 adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. BD Bad Debt Adjustment This is the bad debt passthrough. BN Bonus This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. C5 Temporary Allowance This is the tentative adjustment. CR Capitation Interest This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. CS Adjustment Provide supporting identification information in PLB03-2. CT Capitation Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. CV Capital Passthru CW Certified Registered Nurse Anesthetist Passthru DM Direct Medical Education Passthru E3 Withholding See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. FB Forwarding Balance This is the balance forward. A negative value in PLB04 represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice. A reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information. FC Fund Allocation This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. The specific fund must be identified in PLB03-2. GO Graduate Medical Education Passthru HM Hemophilia Clotting Factor Supplement IP Incentive Premium Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. IR Internal Revenue Service Withholding IS Interim Settlement This is the interim rate lump sum adjustment. J1 Nonreimbursable This offsets the claim or service level data that reflects what could be paid if not for demonstration program or other limitation that prevents issuance of payment. L3 Penalty This is the capitation-related penalty. Withholding or release is identified by the sign in PLB04. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. L6 Interest Owed This is the interest paid on claims in this 835. Support the amounts related to this adjustment by 2-062 AMT amounts, where AMT01 is "I". 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 63 82 LE Levy IRS Levy LS Lump Sum This is the disproportionate share adjustment, indirect medical education passthrough, non-physician passthrough, passthrough lump sum adjustment, or other passthrough amount. The specific type of lump sum adjustment must be identified in PLB03-2. OA Organ Acquisition Passthru OB Offset for Affiliated Providers Identification of the affiliated providers must be made on PLB03-2. PI Periodic Interim Payment This is the periodic interim lump sum payments and reductions (PIP). The payments are made to a provider at the beginning of | /kaggle/input/edi-db/Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 654752ca5715dec30fa59b0a1628633b | 654752ca5715dec30fa59b0a1628633b_14 |
must be identified in PLB03-2. OA Organ Acquisition Passthru OB Offset for Affiliated Providers Identification of the affiliated providers must be made on PLB03-2. PI Periodic Interim Payment This is the periodic interim lump sum payments and reductions (PIP). The payments are made to a provider at the beginning of some period in advance of claims. These payments are advances on the expected claims for the period. The reductions are the recovery of actual claims payments during the period. For instance, when a provider has a PIP payment, claims within this remittance advice covered by that payment would be offset using this code to remove the claim payment from the current check. The sign of the amount in PLB04 determines whether this is a payment (negative) or reduction (positive). This payment and recoupment is effectively a loan to the provider and loan repayment. See section 1.10.2.5, Advance Payments and Reconciliation, for additional information. PL Payment Final This is the final settlement. RA Retro-activity Adjustment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. RE Return on Equity SL Student Loan Repayment TL Third Party Liability This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. WO Overpayment Recovery This is the recovery of previous overpayment. An identifying number must be provided in PLB03-2. See the notes on codes 72 and B3 for additional information about balancing against a provider refund. WU Unspecified Recovery Medicare is currently using this code to represent penalty collections withheld for the IRS (an outside source). PLB-04 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount PLB04 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 64 82 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 65 82 Summary end SE 0200 Summary SE Transaction Set Trailer To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments) Example SE 0000 0001 Max use 1 Required SE-01 96 Transaction Segment Count Min 1 Max 10 Numeric (N0) Required Total number of segments included in a transaction set including ST and SE segments SE-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Numbers in ST02 and SE02 must be identical. The originator assigns the Transaction Set Control Number, which must be unique within a functional group (GS-GE). This unique number also aids in error resolution research. 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 66 82 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE 000000 0000 Max use 1 Required GE-01 97 Number of Transaction Sets Included Min 1 Max 6 Numeric (N0) Required Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element GE-02 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 67 82 IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA 0 000000000 Max use 1 Required IEA-01 I16 Number of Included Functional Groups Min 1 Max 5 Numeric (N0) Required A count of the number of functional groups included in an interchange IEA-02 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 68 82 EDI Samples Example 1: Dollars and Data Sent Separately ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 112233 BPR I 1100 C CHK 20190316 TRN 1 71700666555 1935665544 N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER BL EDI Support TE 2159914290 EM EDI HEALTHPART.COM N1 PE ACME MEDICAL CENTER XX 5544667733 REF TJ 777667755 LX 1 CLP 5554555444 1 800 500 300 HM 94060555410000 11 1 NM1 QC 1 BUDD WILLIAM MI 33344555510 AMT D8 800 SVC HC 99211 800 500 DTM 472 20190301 CAS PR 1 300 AMT B6 800 CLP 8765432112 1 1200 600 600 HM 9407779923000 11 1 NM1 QC 1 SETTLE SUSAN MI 44455666610 AMT D8 1200 SVC HC 93555 1200 600 DTM 472 20190310 CAS PR 1 600 AMT B6 1200 SE 25 112233 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 69 82 Example 2: Multiple Claims Single Check ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 35681 BPR I 810.8 C CHK 20190331 TRN 1 12345 1512345678 REF EV XYZ CLEARINGHOUSE N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER BL EDI Support TE 2159914290 N1 PE | /kaggle/input/edi-db/Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 654752ca5715dec30fa59b0a1628633b | 654752ca5715dec30fa59b0a1628633b_15 |
0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 35681 BPR I 810.8 C CHK 20190331 TRN 1 12345 1512345678 REF EV XYZ CLEARINGHOUSE N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER BL EDI Support TE 2159914290 N1 PE BAN DDS LLC XX 9999947036 REF TJ 212121212 LX 1 CLP 7722337 1 226 132 HM 119932404007801 11 1 NM1 QC 1 DOE SANDY MI SJD11112 NM1 82 1 BAN ERIN XX 1811901945 AMT D8 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190324 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 119 74 HM 119932404007801 11 1 NM1 QC 1 DOE SALLY MI SJD11111 NM1 82 1 BAN ERIN XX 1811901945 AMT D8 74 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 226 108 24 HM 119932404007801 11 1 NM1 QC 1 SMITH SALLY MI SJD11113 NM1 82 1 BAN ERIN XX 1811901945 AMT D8 132 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 70 82 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0220 25 0 DTM 472 20190324 CAS PR 3 14 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 0 DTM 472 20190324 CAS PR 3 10 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 1145 14 902 HM 119932404007801 11 1 NM1 QC 1 SMITH SAM MI SJD11116 NM1 82 1 BAN ERIN XX 1811901945 AMT D8 14 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 45 11 AMT B6 14 SVC AD D2790 940 0 DTM 472 20190324 CAS PR 3 756 CAS CO 45 184 SVC AD D2950 180 0 DTM 472 20190324 CAS PR 3 146 CAS CO 45 34 CLP 7722337 1 348 16.8 44.2 HM 119932404007801 11 1 NM1 QC 1 JONES SAM MI SJD11122 NM1 82 1 BAN ERIN XX 1811901945 AMT D8 28 SVC AD D4342 125 0 DTM 472 20190313 CAS CO 45 125 SVC AD D4381 43 0 DTM 472 20190313 CAS PR 3 33 CAS CO 45 10 SVC AD D2950 180 16.8 DTM 472 20190313 CAS PR 3 11.2 CAS CO 45 152 AMT B6 28 CLP 7722337 1 226 132 HM 119932404007801 11 1 NM1 QC 1 JONES SALLY MI SJD11133 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 71 82 NM1 82 1 BAN ERIN XX 1811901945 AMT D8 132 SVC AD D0120 46 25 DTM 472 20190321 CAS CO 45 21 AMT B6 25 SVC AD D0220 25 14 DTM 472 20190321 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190321 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190321 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190321 CAS CO 45 24 AMT B6 49 CLP 7722337 1 179 108 HM 119932404007801 11 1 NM1 QC 1 DOE SAM MI SJD99999 NM1 82 1 BAN ERIN XX 1811901945 AMT D8 108 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 129 82 HM 119932404007801 11 1 NM1 QC 1 DOE SUE MI SJD88888 NM1 82 1 BAN ERIN XX 1811901945 AMT D8 82 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D1120 54 37 DTM 472 20190324 CAS CO 45 17 AMT B6 37 SVC AD D1208 29 20 DTM 472 20190324 CAS CO 45 9 AMT B6 20 CLP 7722337 1 221 144 HM 119932404007801 11 1 NM1 QC 1 DOE DONNA MI SJD77777 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 72 82 NM1 82 1 BAN ERIN XX 1811901945 AMT D8 144 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0330 92 62 DTM 472 20190324 CAS CO 45 30 AMT B6 62 SVC AD D1120 54 37 DTM 472 20190324 CAS CO 45 17 AMT B6 37 SVC AD D1208 29 20 DTM 472 20190324 CAS CO 45 9 AMT B6 20 SE 182 35681 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 73 82 Example 3: Claim Specific Negotiated Discount ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 35681 BPR I 132 C CHK 20190331 TRN 1 12345 1512345678 REF EV CLEARINGHOUSE N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER BL EDI Support TE 2159914290 N1 PE BAN DDS LLC FI 999994703 LX 1 CLP 7722337 1 226 132 HM 119932404007801 NM1 QC 1 DOE SALLY MI SJD11111 NM1 82 1 BAN ERIN XX 1811901945 AMT | /kaggle/input/edi-db/Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 654752ca5715dec30fa59b0a1628633b | 654752ca5715dec30fa59b0a1628633b_16 |
PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER BL EDI Support TE 2159914290 N1 PE BAN DDS LLC FI 999994703 LX 1 CLP 7722337 1 226 132 HM 119932404007801 NM1 QC 1 DOE SALLY MI SJD11111 NM1 82 1 BAN ERIN XX 1811901945 AMT D8 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 131 21 AMT B6 25 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 131 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190324 CAS CO 131 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 131 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 131 24 AMT B6 49 SE 35 35681 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 74 82 Example 4: Claim Adjustment Reason Code 45 ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 80.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER CX TE 2159914350 PER BL EDI Support TE 2159914290 EM EDI HEALTHPART.COM PER IC UR www.healthpart.com N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PATACCT 1 400 80 HM CLAIMNUMBER 11 1 NM1 QC 1 DOE JOHN N MI ABC123456789 DTM 050 20190209 AMT D8 150 SVC HC 99213 150 80 1 DTM 472 20190101 CAS CO 45 70 AMT B6 80 SVC HC 85003 100 0 1 DTM 472 20190101 CAS CO 204 100 SVC HC 36415 150 0 1 DTM 472 20190101 CAS CO 97 150 SE 30 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 75 82 Example 5a: Line Service Tax impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 11.06 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER CX TE 2159914350 PER BL EDI Support TE 2159914290 EM EDI HEALTHPART.COM PER IC UR www.healthpart.com N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PCN 1 36.20 11.06 HM CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 DTM 050 20170113 AMT D8 36.20 SVC HC 99214 26.2 3.06 DTM 472 20170109 CAS CO 45 23.2 REF 6R B1 AMT B6 3 SVC HC 36415 10 8 DTM 472 20170109 CAS CO 45 2 REF 6R B2 AMT B6 8 SE 31 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 76 82 Example 5b: Line Service Bonuses impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 12.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER CX TE 2159914350 PER BL EDI Support TE 2159914290 EM EDI HEALTHPART.COM PER IC UR www.healthpart.com N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PCN 1 25 12 10 HM CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 DTM 050 20170113 AMT D8 25 SVC HC 99214 25 12 DTM 472 20170109 CAS CO 45 5 CAS PR 3 10 REF 6R 123 AMT B6 20 SE 27 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 77 82 Example 5c: Line Service Penalty impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 8.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER CX TE 2159914350 PER BL EDI Support TE 2159914290 EM EDI HEALTHPART.COM PER IC UR www.healthpart.com N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PCN 1 25 8 10 HM CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 DTM 050 20170113 AMT D8 25 SVC HC 99214 25 8 DTM 472 20170109 CAS CO 45 5 CAS PR 3 10 REF 6R 123 AMT B6 20 SE 27 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 78 82 Example 6: Not Covered Not Authorized Inpatient Facility claim days ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 8000.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER CX TE 2159914350 PER BL EDI Support TE 2159914290 EM EDI HEALTHPART.COM PER IC UR www.healthpart.com N1 PE PROVIDER XX | /kaggle/input/edi-db/Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 654752ca5715dec30fa59b0a1628633b | 654752ca5715dec30fa59b0a1628633b_17 |
BPR I 8000.00 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER CX TE 2159914350 PER BL EDI Support TE 2159914290 EM EDI HEALTHPART.COM PER IC UR www.healthpart.com N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PATACCT 1 40000 8000 HM CLAIMNUMBER 11 1 CAS CO 197 2000 1 NM1 QC 1 DOE JOHN N MI ABC123456789 DTM 050 20190209 AMT D8 38000 SE 21 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 79 82 Example 8a: Claim submitted with incorrect subscriber as patient and incorrect ID ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 120.03 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER CX TE 2159914350 PER BL EDI Support TE 2159914290 EM EDI HEALTHPART.COM PER IC UR www.healthpart.com N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP 04777796TLC777122 1 155 120.03 HM 8838888212 11 1 NM1 QC 1 MASTERS MARVIN L MI 80444444403 NM1 82 1 SHELTON MD BLAKE XX 1666666666 DTM 050 20181119 AMT D8 155 SVC HC 99393 155 120.03 1 DTM 472 20181114 CAS CO 45 34.97 REF LU 11 REF 6R 22261822 AMT B6 120.03 SE 27 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 80 82 Example 8b: Claim submitted with incorrect subscriber name and ID ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 35.06 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER CX TE 2159914350 PER BL EDI Support TE 2159914290 EM EDI HEALTHPART.COM PER IC UR www.healthpart.com N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP 02333TLC222222 1 115 35.06 35 HM 8333333214 11 1 NM1 QC 1 KEATON ALEX P MI 80000006006 NM1 82 1 BLOOD MD RED N XX 1888888886 DTM 050 20191119 AMT D8 115 SVC HC 99213 115 35.06 1 DTM 472 20191113 CAS CO 45 44.94 CAS PR 3 35 REF LU 11 REF 6R 22261389 AMT B6 70.06 SE 28 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 81 82 Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including X12, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation. Example 8c: Claim submitted with for subscriber missing the Middle initial ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 2415.25 C CHK 20190816 TRN 1 CK NUMBER 1 1234567890 REF EV FAC N1 PR Health Partners of Philadelphia N3 901 Market St N4 Philadelphia PA 19107 PER CX TE 2159914350 PER BL EDI Support TE 2159914290 EM EDI HEALTHPART.COM PER IC UR www.healthpart.com N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP 05444444TLC999999 1 3903 2415.25 HM 8777777782 21 1 NM1 QC 1 GONZALES SAMMY MI 80455555502 NM1 82 1 GOOD MD ROBERT B XX 19999999987 DTM 050 20191114 AMT D8 3903 AMT I 150 SVC HC 59400 3903 2415.25 1 DTM 472 20191101 CAS CO 45 1487.75 REF LU 21 REF 6R 22215592 AMT B6 2415.25 SE 28 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view health-partner-plans health-care-claim-paymentadvice-x221a1 01H16H5SPA8ZB874WBF4EWR25K 82 82 | /kaggle/input/edi-db/Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 654752ca5715dec30fa59b0a1628633b | 654752ca5715dec30fa59b0a1628633b_18 |
HIPAA Transaction Standard Companion Guide 835 Health Care Claim Payment Advice Refers to the Implementation Guides Based on X12 version 005010 Errata Companion Guide Version Number: 1.1 February 2024 Disclaimer Statement The Health Insurance Portability and Accountability Act (HIPAA), sections 160 and 162, require that health care providers, health plans, and health care clearing houses comply with the EDI standards for health care. The HIPAA implementation specifications for ASC X12N standards may be obtained through the Washington Publishing Company on the Internet at http: www.wpcedi.com. The purpose of this companion guide is solely to supplement the HIPAA ASC X12N standards, to provide clarification to the ASC X12N standards, and should not be interpreted as a contract, amendment to a contract or an addendum to a contract. In any instance where this companion guide differs from the HIPAA ASC X12N Implementation Guides, the HIPAA ASC X12N standards shall govern. Substantial effort has been taken to minimize errors; however, SummaCare, Inc, its agents, employees, directors and shareholders shall not be liable or responsible for any errors, omissions or expenses resulting from the use of the information in this document Page of SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 Table of Contents 1 Introduction................................................................................................................................................4 1.1 Overview 2 Eligibility 3 Data Exchange Frequency 4 Electronic Funds Transfer (EFT) 5 Claim Remittance Processing...................................................................................................................5 5.1 Interchange Control Structure 5.2 Sorting order of data within the 835 file 5.3 Claims returned within the 835 6 Claims Batch Matching 7 Bundling Unbundling 8 Identification Codes and Numbers............................................................................................................6 8.1 Provider Identifiers 8.2 Subscriber Identifiers 8.3 Payer Claim Control Number 8.4 Adjustment Group and Reason Codes 8.5 Remarks Codes 9 Special Handling.......................................................................................................................................6 9.1 Federal Surprise Act (NSA) 10 Inquiries...............................................................................................................................................7-10 11 835 Data Element Table 11.1 835 Health Care Claim Payment Advice Header 11.2 835 Health Care Claim Payment Advice Detail 11.3 835 Health Care Claim Payment Advice Summary 12 835 Claim Payment Advice Transaction Sample..............................................................................11-12 12.1 Claim Payment Advice Scenario 12.2 Claim Payment Advice Example ANSI X 12 13 Version History.......................................................................................................................................12 14 Frequently Asked Questions FAQ.......................................................................................................13 Page of SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 1 Introduction 1.1 Overview This Companion Guide identifies unique information processing or adjudication needs specific to SummaCare, Inc in its implementation of the 835 Health Care Claim Payment Advice and should be used in conjunction with the HIPAA 835 Implementation Guide. Throughout this document, SummaCare represents SummaCare, Inc. This companion guide contains three categories of information: General information applicable to the processing of claims and business edits performed by SummaCare. The transaction table outlining specific requests for data format or content within the transaction, or describing SummaCare handling of specific data types. Additional information containing a sample scenario and frequently asked questions (FAQ). All claims (paper and electronic) will be reported on the 835, if a provider submitter chooses to receive the 835. While SummaCare accepts all ASCX12 compliant transactions, the HIPAA Implementation Guides allow for some discretion in applying the regulations to existing business practices. Understanding SummaCare business practices may expedite claims processing for trading partners as they exchange EDI transactions with SummaCare. 2 Eligibility In order to receive an 835 Health Care Claim Payment Advice, submitters of health care claims can complete the following: Complete and submit a Trading Partner Agreement to SummaCare or enter into a contractual agreement with a SummaCare contracted Trading Partner. Complete the SummaCare 835 Registration Form. Complete testing requirements with SummaCare. 3 Data Exchange Frequency New files may be available each business day by noon eastern standard time. 4 Electronic Funds Transfer (EFT) The SummaCare 835 Transaction is for notification only and does not include Electronic Fund Transfer (EFT) to financial institutions. Providers who would like to Implement EFT can log into their Plan Central account and register or complete the EFT form on SummaCare s website at http: www.summacare.com Provider ResourcesAndSelfServices EDIRegistration.aspx, complete and mail in the EFT Registration Form to the address on the form. Page of SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 5 Claim Remittance Processing 5.1 Interchange Control Structure 835 transactions are generated one file per Trading Partner during each scheduled payables process. The envelope structure is as follows for each individual check processed within a file. If a Trading Partner receives more than one check payment within the 835 then there will be multiple iterations of the structure below within the file. ISA - Interchange Control Header GS - Functional Group header ST - Transaction Set Header Detail Segments (Please see the Implementation Guide for All possible detail segments) SE - Transaction Set Trailer GE - Functional Group Trailer IEA - Interchange Control Trailer 5.2 Sorting order of data within the 835 file Within the 835 transaction file the Interchange Control Structure(s) are ordered by check number in ascending order. The check number is located in the TRN02 segment. For each check within the 835 transaction the claims are ordered by claim number in ascending order. The claim number is located in the CLP07 segment. 5.3 Claims returned within the 835 Notes that are important to claims processing are as follows: 835 Transactions are only generated for claims that have a "paid" or "denied" status. Claims still in the adjudication process or returned with an error messages do not receive an 835 response. If a provider submits claims on paper and EDI claims, SummaCare will generate a format compliant 835 Health Care Claim Payment Advice transaction with required elements. However, the content of the resulting 835 will not be as complete as an 835 resulting from an electronic 837 Claim transaction. SummaCare will turn off the paper Explanation of Payments (EOP) once a provider starts receiving the 835 transaction. The provider may access Plan Central to review a Portable Document Format (PDF) image of their EOP. To register and access this service please visit http: www.summacare.com Provider ResourcesAndSelfServices.aspx 6 Claims Batch Matching Please note that there is not batch matching between 837 Health Care Claims and 835 Health Care Claim Payment Advice. 7 Bundling Unbundling As claims are processed, professional services reflected by procedure codes are bundled or | /kaggle/input/edi-db/HIPAA SummaCare 835 Companion Guide 5010.pdf | cc2a69e2b30150b39da3b2fb5d2927af | cc2a69e2b30150b39da3b2fb5d2927af_0 |
and access this service please visit http: www.summacare.com Provider ResourcesAndSelfServices.aspx 6 Claims Batch Matching Please note that there is not batch matching between 837 Health Care Claims and 835 Health Care Claim Payment Advice. 7 Bundling Unbundling As claims are processed, professional services reflected by procedure codes are bundled or unbundled utilizing SummaCare business processes. Procedure codes are returned for professional health care claims as processed reflecting SummaCare payment record. This does not necessarily reflect procedure codes submitted. Page of SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 8 Identification Codes and Numbers SummaCare uses the standard medical and non-medical code sets indicated in Appendix C of the 835 Payment Advice Remittance Implementation Guide. 8.1 Provider Identifiers SummaCare accepts the National Provider Identifier and Tax Identification numbers for provider's mandated by the state to obtain one. For exempt providers we will accept the Tax Identification number. 8.2 Subscriber Identifiers The Subscriber Identifier returned on the 835 Claim Payment Advice is the membership identifier that appears within the SummaCare system which could be different than what was submitted on the 837 Health Care Claims transaction. If this identifier differs from that which was submitted, assume the returned identifier on the 835 transactions is correct. 8.3 Payer Claim Control Number The Payer Claim Control Number (Payer Patient Control Number in the 2100 loop, CLP07) is the 12-digit claim number assigned to each claim by SummaCare. Receivers of the 835 Health Care Claim Payment Advice should use their Patient Control Number (Patient Control Number CLP01) and dates of service, in conjunction with the CLP07 value to match claims with remittances. If the Patient Control Number is submitted on paper claims, then this number will be returned on the 835 Health Care Claim Payment Advice. If there is no Patient Control Number on the paper claim, then the value of "0" will be returned. 8.4 Adjustment Group and Reason Codes For claim adjustment reason code use code source 139 and for Health Care Remark Codes, use source code 411. 8.5 Remarks Codes We will be returning the HIPAA Standard Remarks Codes (Loop2110, segment LQ02) along with our current Explanation Codes (Loop 2110, segment REF02). 9 Special Handling In the event that we are unable to produce an 835 Health Care Claim Payment Advice electronically, SummaCare will generate a paper Explanation of Payment (EOP). 9.1 Federal No Surprises Act (NSA) SummaCare complies with both federal and state NSA requirements. When RARC code N862 is found in the LQ segment, please reference additional information regarding federal NSA on SummaCare.com using the following link: https: www.summacare.com no-surprises-act 10 Inquiries For inquiries concerning the EFT (Electronic Funds Transfer) please contact our Finance Department at (330) 996-8461. All other inquiries should contact: SummaCare Provider Support Services at (330) 996-8400 or 1-800-996-8401 or by email: contactproviderservices summacare.com. Page of SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 11 835 Data Element Table 11.1 835 Health Care Claim Payment Advice Header The 835 Transaction Set Header contains general information about the claim payment, such as Payee,Amount,Payer,Payment method, and Trace Number. The following table explains the header segments and data elements that require specific information for SummaCare processing. Envelope Section Label Segment Description Value Options for SummaCare Description Comments Financial Information BPR01 Transaction Handling Code I, C, D I - Remittance information only C-Payment Accompanies Remittance Advice D- Make payment only Financial Information BPR03 Credit Debit Flag Code C C - Credit Financial Information BPR04 Payment Method Code ACH, CHK ACH - Automated Clearing House CHK - Check Financial Information BPR05 Payment Format Code CCP CCP - Cash Concentration Disbursement plus Addenda Financial Information BPR06 DFI ID Number Qualifier 01 01 - ABA Transit Routing Number Including Check Digit (9 digits) Financial Information BPR07 Sender DFI ID Number Sender DFI ID Represents Summa Insurance Company Summa Health Network SummaCare Bank Number Financial Information BPR09 Sender Bank Account Number Sender Bank Account Number Represents Summa Insurance Company Summa Health Network SummaCare Bank Account Number Financial Information BPR10 Originating Company Identifier Same value as the TRN03 This will be sent when the BPR04 is present Financial Information BPR12 DFI ID Number Qualifier 01 01 - ABA Transit Routing Number Including Check Digit (9 digits) Financial Information BPR13 Receiver DFI ID Number Receiver DFI ID Represents Receiver Provider's Bank Number Financial Information BPR15 Receiver Bank Account Number Receiver Bank Account Number Represents Receiver Provider's Bank Account Number Financial Information BPR16 Check Issue or EFT Effective Date Date Represent the Check Issue Date or EFT Effective Date Re-association Trace Number TRN02 Check or EFT Trace Number Check Number, Advice Number Check Number- If the Provider Receives a Paper Check Advice Number - If the Provider Receives an EFT Re-association Trace Number TRN03 Payer Identifier 95202 SummaCare Payer Identification Number Receiver Identification REF01 Reference Identification Qualifier EV EV - Receiver ID Number Receiver Identification REF02 Receiver Identifier Receiver's EDI Sender ID Number Represents the Receiver's EDI Sender ID Number Assigned by SUMMACARE Table 1 - 835 Claim Payment Advice - Header Transaction Set Header LOOP ID - 1000B Payee Identification Payee Identification N103 Identification Code Qualifier XX or FI XX - Centers for Medicare and Medicaid Services National Provider Identifier(NPI) FI - Federal Tax Identification (This should only be sent for Exempt Providers) Payee Identification N104 Payee Identification Code Provider s NPI Number or Tax ID number Represents the Provider's NPI number or Federal Tax ID number. Page of SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 11.2 835 Health Care Claim Payment Advice Detail The 835 Payment Advice detail level contains the explanations of benefits and charges paid, reduced, or denied related to the adjudicated claims and services. The Claim Payment and Service Patient Information are contained in Loops 2100 and 2110 in the following table. The table also explains the situational segments and data elements that require specific information for SummaCare processing. Table 2 - 835 Claim Payment Advice - Detail LOOP ID - 2100 Claims Payment Information Envelope Section Label Segment Description Value Options for SummaCare Description Comments Claim Payment Information CLP01 Patient | /kaggle/input/edi-db/HIPAA SummaCare 835 Companion Guide 5010.pdf | cc2a69e2b30150b39da3b2fb5d2927af | cc2a69e2b30150b39da3b2fb5d2927af_1 |
table. The table also explains the situational segments and data elements that require specific information for SummaCare processing. Table 2 - 835 Claim Payment Advice - Detail LOOP ID - 2100 Claims Payment Information Envelope Section Label Segment Description Value Options for SummaCare Description Comments Claim Payment Information CLP01 Patient Control Number Patient Control Number (UB04) Patient Account Number (HCFA) For Electronic Claims, this field will contain the value received in CLM01 on the inbound 837. For Paper Claims, this field will contain the value received in block 26 on the HCFA and block 3a on the UB04 claim forms. If the patient control number was not present on the inbound claim, a zero will appear here. Claim Payment Information CLP07 Payer Claim Control Number SUMMACARE Claim Number Represents the claim number assigned by SUMMACARE Patient Name NM108 Identification Code Qualifier MI MI - Member Identification Number Patient Name NM109 Patient Identifier SummaCare member number plus 2 digit suffix Represents the Member Identification Number Insured Name NM108 Identification Code Qualifier MI This segment is only used when the patient is not the subscriber MI - Member Identification Number Insured Name NM109 Patient Identifier SummaCare Subscriber's number This segment is only used when the patient is not the subscriber Represents the Member Identification Number Service Provider Name NM108 Identification Code Qualifier XX or FI XX -Centers for Medicare and Medicaid Services National Provider Identifier(NPI) FI - Federal Tax Identification(This should only be sent for Exempt Providers) Service Provider Name NM109 Identification Code Provider s NPI Number or Tax ID Number Represents the Provider ID Claim Date DTM01 Date Time Qualifier One of the following values: 232,233 232- Claim Statement Period Start 233 - Claim statement Period End Claim Date DTM02 Date Date specified by the code used in DTM01 Date specified by the code used in DTM01 LOOP ID - 2110 Service Payment Information Service Payment Information SVC01-1 Product or Service ID Qualifier One of the following values: AD HC NU AD - American Dental Association Codes HC - Health Care Financing Administration Common Procedural Coding System Codes (HCPCS) NU - National Uniform Billing Committee Codes (NUBC) UB92 codes Service Payment Information SVC06-2 Product Service ID Procedure Code This element will be used if the submitted procedure code was bundled.The new bundled procedure code will be placed here. Service Date DTM01 Date Time Qualifier One of the following values: 150, 151 or 472 150 - Service Period Start 151 - Service Period End 472 - Service Service Date DTM02 Date Service date Service date Service Identification REF01 Reference Identification Qualifier E9 E9 - Attachment Code Service Identification REF02 Reference Identification EX codes attached to the Service Line without the description of the EX Code. This represents SummaCare s internal explanation code that is shown on the paper EOP. Page of SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 11.3 835 Health Care Claim Payment Advice Summary The summary level contains the Provider Level Adjustment Segment and provides information related to adjustments to the payment amount not specific to the Detail level. The adjustments can either increase or decrease the actual payment. The following table also explains the situational segments and data elements that require specific information for SummaCare Processing. Table 3 - 835 Claim Payment Advice - Summary Envelope Section Label Segment Description Value Options for SummaCare Description Comments Provider Level Adjustment PLB01 Provider Identifier Payee ID Number Represents the Payee NPI. If the Payee is not required under the Mandate to acquire an NPI Number this will represent the ID Number assigned by SUMMACARE. Page of 12 835 Claim Payment Advice Transaction Sample 12.1 Claim Payment Advice Scenario On September 2, 2023, Jonathan Doe was experiencing pain in his leg and ankle. He was taken to Healthy Hospital for an x-ray of his foot and ankle. The hospital submitted the bill to their clearinghouse. On September 18, 2023, the clearinghouse transmitted a claim to SummaCare in the 837I file format, for 583.70. On September 25, 2023, SummaCare issued a check for 171.55 to Healthy Hospital for their services. Claim Information Payment: 175.11 Check Date: 9 25 2023 Facility Billed Amount: 583.70 Check: 97CF0000000411 Facility TIN: 207661234 Claim Production run date: 9 18 2023 Payer Name: SummaCare Payer Address: 1200 E. Market Street Suite 400 Akron, OH 44305-4018 Facility: Healthy Hospital Facility National Provider Identification (NPI) Number: 1234567890 Patient: Jonathan Doe Patient ID: 98765432103 Patient Account: 330866922 Date of Service: 9 2 2023 CPT Codes: 73610, 73630 Revenue Codes: 320 Adjustment: 408.59 due to a contractual obligation Provider System Control: 230920E03109 SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 Page of 12.2 Claim Payment Advice Example ANSI X 12 ST 835 3207 BPR I 175.11 C CHK 20230925 TRN 1 97CF0000000411 207661234 DTM 405 20230918 N1 PR SUMMACARE N3 1200 E. MARKET STREET SUITE 400 N4 AKRON OH 44305 N1 PE HEALTHY HOSPITAL FI 123456789 N3 PO BOX 625 N4 BURLINGTON VT 05402 REF PQ V299 LX 1 CLP 330866922 1 583.7 175.11 13 230920E03109 13 1 NM1 QC 1 DOE JONATHAN MI 98765432103 NM1 IL 1 DOE JONATHAN MI 987654321 NM1 82 2 HEALTHY HOSPITAL XX 1234567890 DTM 232 20230902 DTM 233 20230902 SVC HC:73610 297.40 89.22 320 1 DTM 472 20230902 CAS CO 45 208.18 REF E9 PA AMT B6 89.22 SVC HC:73630 286.30 85.89 320 1 DTM 472 20230902 CAS CO 45 200.41 REF E9 PA AMT B6 85.89 SE 22 3207 SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 13 Version History The following Version History is provided to easily identify updates from the last version of this Companion Guide. Page of Version Date Updated Update 1.0 April 2023 Added: 9.1 Federal No Surprises Act (NSA) SummaCare complies with both federal and state NSA requirements. When RARC code N862 is found in the LQ segment, please reference additional information regarding federal NSA on SummaCare.com using the following link: https: www.summacare.com no-surprises-act 1.1 February 2024 Update: Examples given on pages 9 and 10 were updated with more current information. 14 Frequently Asked Questions - FAQ 1. What | /kaggle/input/edi-db/HIPAA SummaCare 835 Companion Guide 5010.pdf | cc2a69e2b30150b39da3b2fb5d2927af | cc2a69e2b30150b39da3b2fb5d2927af_2 |
RARC code N862 is found in the LQ segment, please reference additional information regarding federal NSA on SummaCare.com using the following link: https: www.summacare.com no-surprises-act 1.1 February 2024 Update: Examples given on pages 9 and 10 were updated with more current information. 14 Frequently Asked Questions - FAQ 1. What is Electronic Data Interchange? Electronic Data Interchange (EDI) allows providers to submit claims, retrieve remittance advices and retrieve claim file acknowledgements from their computer system to the insurance carrier or clearinghouse. 2. Can I receive my payment and Explanation of Payment Electronically (EOP)? Yes. Providers can receive an Electronic Fund Transfer (EFT) Automated Clearing House (ACH) payment after an EFT Registration form is completed and mailed back to SummaCare. Providers may review their EOP utilizing SummaCare's Provider self service tool of Plan Central. To register or to locate the EFT Registration form please go to http: www.summacare.com Provider ResourcesAndSelfServices.aspx. 3. Do you send data on all claims or just paid claims? We send data on all paid, denied and zero dollar charge claims. Data is not returned on electronic claims rejected at time of submission or claims in process in our system. 4. Do you send paper Explanation of Payment along with the electronic version? No, SummaCare will turn off the paper Explanation of Payments (EOP) once a provider starts receiving the 835 transaction. The provider may access Plan Central to review a Portable Document Format (PDF) image of their EOP by going to the following SummaCare website http: www.summacare.com Provider ResourcesAndSelfServices.aspx. 5. As a provider can I receive my 835 directly from SummaCare? Yes, SummaCare can set up a direct File Transfer Protocol (FTP) secure internet connection for the provider to directly pick up their 835 from SummaCare. SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 | /kaggle/input/edi-db/HIPAA SummaCare 835 Companion Guide 5010.pdf | cc2a69e2b30150b39da3b2fb5d2927af | cc2a69e2b30150b39da3b2fb5d2927af_3 |
Stedi maintains this guide based on public documentation from Security Health. Contact Security Health for official EDI specifications. To report any errors in this guide, please contact us. X12 835 Health Care Claim Payment Advice (X221A1) X12 Release 5010 Revised November 20, 2023 Go to Stedi Network This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Payment Advice Transaction Set (835) for use within the context of the Electronic Data Interchange (EDI) environment. This transaction set can be used to make a payment, send an Explanation of Benefits (EOB) remittance advice, or make a payment and send an EOB remittance advice only from a health insurer to a health care provider either directly or via a financial institution. Delimiters Segment Element Component Repetition View the latest version of this implementation guide as an interactive webpage https: www.stedi.com app guides view security-health health-care-claim-paymentadvice- x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE POWERED BY Build EDI implementation guides at stedi.com 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 1 124 Overview ISA - Interchange Control Header Max use 1 Required GS - Functional Group Header Max use 1 Required Heading ST 0100 Transaction Set Header Max use 1 Required BPR 0200 Financial Information Max use 1 Required TRN 0400 Reassociation Trace Number Max use 1 Required CUR 0500 Foreign Currency Information Max use 1 Optional REF 0600 Receiver Identification Max use 1 Optional REF 0600 Version Identification Max use 1 Optional DTM 0700 Production Date Max use 1 Optional Payer Identification Loop N1 0800 Payer Identification Max use 1 Required N3 1000 Payer Address Max use 1 Required N4 1100 Payer City, State, ZIP Code Max use 1 Required REF 1200 Additional Payer Identification Max use 4 Optional PER 1300 Payer Business Contact Information Max use 1 Optional PER 1300 Payer Technical Contact Information Max use 1 Required PER 1300 Payer WEB Site Max use 1 Optional Payee Identification Loop N1 0800 Payee Identification Max use 1 Required N3 1000 Payee Address Max use 1 Optional N4 1100 Payee City, State, ZIP Code Max use 1 Optional REF 1200 Payee Additional Identification Max use 1 Optional RDM 1400 Remittance Delivery Method Max use 1 Optional Detail Header Number Loop LX 0030 Header Number Max use 1 Required TS3 0050 Provider Summary Information Max use 1 Optional TS2 0070 Provider Supplemental Summary Information Max use 1 Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 2 124 Claim Payment Information Loop CLP 0100 Claim Payment Information Max use 1 Required CAS 0200 Claim Adjustment Max use 99 Optional NM1 0300 Corrected Patient Insured Name Max use 1 Optional NM1 0300 Corrected Priority Payer Name Max use 1 Optional NM1 0300 Crossover Carrier Name Max use 1 Optional NM1 0300 Insured Name Max use 1 Optional NM1 0300 Other Subscriber Name Max use 1 Optional NM1 0300 Patient Name Max use 1 Required NM1 0300 Service Provider Name Max use 1 Optional MIA 0330 Inpatient Adjudication Information Max use 1 Optional MOA 0350 Outpatient Adjudication Information Max use 1 Optional REF 0400 Other Claim Related Identification Max use 5 Optional REF 0400 Rendering Provider Identification Max use 10 Optional DTM 0500 Claim Received Date Max use 1 Optional DTM 0500 Coverage Expiration Date Max use 1 Optional DTM 0500 Statement From or To Date Max use 2 Optional PER 0600 Claim Contact Information Max use 2 Optional AMT 0620 Claim Supplemental Information Max use 13 Optional QTY 0640 Claim Supplemental Information Quantity Max use 14 Optional Service Payment Information Loop SVC 0700 Service Payment Information Max use 1 Required DTM 0800 Service Date Max use 2 Optional CAS 0900 Service Adjustment Max use 99 Optional REF 1000 HealthCare Policy Identification Max use 5 Optional REF 1000 Line Item Control Number Max use 1 Optional REF 1000 Rendering Provider Information Max use 10 Optional REF 1000 Service Identification Max use 8 Optional AMT 1100 Service Supplemental Amount Max use 9 Optional QTY 1200 Service Supplemental Quantity Max use 6 Optional LQ 1300 Health Care Remark Codes Max use 99 Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 3 124 Summary PLB 0100 Provider Adjustment Max use 1 Optional SE 0200 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 4 124 ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange- related control segments Example ISA 00 00 XX XXXXXXXXXXXXXX X XX XXXXXXXXXXXXXXX 250130 0724 00501 00000000 0 X X Max use 1 Required ISA-01 I01 Authorization Information Qualifier Identifier (ID) Required Code identifying the type of information in the Authorization Information 00 No Authorization Information Present (No Meaningful Information in I02) ISA-02 I02 Authorization Information Min 10 Max 10 String (AN) Required Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01) ISA-03 I03 Security Information Qualifier Identifier (ID) Required Code identifying the type of information in the Security Information 00 No Security Information Present (No Meaningful Information in I04) ISA-04 I04 Security Information Min 10 Max 10 String (AN) Required This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03) ISA-05 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-06 I06 Interchange Sender ID Min 15 Max 15 | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_0 |
information is set by the Security Information Qualifier (I03) ISA-05 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-06 I06 Interchange Sender ID Min 15 Max 15 String (AN) Required Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element ISA-07 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 5 124 Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-08 I07 Interchange Receiver ID Min 15 Max 15 String (AN) Required Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them ISA-09 I08 Interchange Date YYMMDD format Date (DT) Required Date of the interchange ISA-10 I09 Interchange Time HHMM format Time (TM) Required Time of the interchange ISA-11 I65 Repetition Separator Min 1 Max 1 String (AN) Required Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator Repetition Separator ISA-12 I11 Interchange Control Version Number Identifier (ID) Required Code specifying the version number of the interchange control segments 00501 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003 ISA-13 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender ISA-14 I13 Acknowledgment Requested Min 1 Max 1 Identifier (ID) Required Code indicating sender's request for an interchange acknowledgment 0 No Interchange Acknowledgment Requested 1 Interchange Acknowledgment Requested (TA1) ISA-15 I14 Interchange Usage Indicator Min 1 Max 1 Identifier (ID) Required Code indicating whether data enclosed by this interchange envelope is test, production or information I Information 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 6 124 P Production Data T Test Data ISA-16 I15 Component Element Separator Min 1 Max 1 String (AN) Required Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator Component Element Separator 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 7 124 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GS HP XXXXXXX XXXX 20250130 1743 0000 X 005010X22 1A1 Max use 1 Required GS-01 479 Functional Identifier Code Identifier (ID) Required Code identifying a group of application related transaction sets HP Health Care Claim Payment Advice (835) GS-02 142 Application Sender's Code Min 2 Max 15 String (AN) Required Code identifying party sending transmission; codes agreed to by trading partners GS-03 124 Application Receiver's Code Min 2 Max 15 String (AN) Required Code identifying party receiving transmission; codes agreed to by trading partners GS-04 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year GS-05 337 Time HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time (TM) Required Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H hours (00-23), M minutes (00-59), S integer seconds (00-59) and DD decimal seconds; decimal seconds are expressed as follows: D tenths (0-9) and DD hundredths (00-99) GS-06 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480 T Transportation Data Coordinating Committee (TDCC) X Accredited Standards Committee X12 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 8 124 GS-08 480 Version Release Industry Identifier Code String (AN) Required Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed 005010X221A1 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 9 124 Heading ST 0100 Heading ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST 835 0001 Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) Required Code uniquely identifying a Transaction Set The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set). Usage notes The only valid value within this transaction set for ST01 is 835. 835 Health Care Claim Payment Advice ST-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_1 |
selects the Invoice Transaction Set). Usage notes The only valid value within this transaction set for ST01 is 835. 835 Health Care Claim Payment Advice ST-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Start with a number, for example 0001, and increment from there. This number must be unique within a specific group and interchange, but it can be repeated in other groups and interchanges. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 10 124 BPR 0200 Heading BPR Financial Information To indicate the beginning of a Payment Order Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and or information from payer to payee to occur Usage notes Use the BPR to address a single payment to a single payee. A payee may represent a single provider, a provider group, or multiple providers in a chain. The BPR contains mandatory information, even when it is not being used to move funds electronically. Example BPR H 000000000000000 D CHK CCP 01 XXXXXXXX D A X 1391572880 XXXXXXXXX 01 XXXXX DA XXX 2025013 0 If either Depository Financial Institution (DFI) Identification Number Qualifier (BPR-06) or Sender DFI Identifier (BPR-07) is present, then the other is required If Account Number Qualifier (BPR-08) is present, then Sender Bank Account Number (BPR-09) is required If either Depository Financial Institution (DFI) Identification Number Qualifier (BPR-12) or Receiver or Provider Bank ID Number (BPR-13) is present, then the other is required If Account Number Qualifier (BPR-14) is present, then Receiver or Provider Account Number (BPR-15) is required Max use 1 Required BPR-01 305 Transaction Handling Code Identifier (ID) Required Code designating the action to be taken by all parties H Notification Only Use this code when the actual provider payment (BPR02) is zero and the transaction is not being used for Prenotification of Future Transfers. This indicates remittance information without any associated payment. I Remittance Information Only Use this code to indicate to the payee that the remittance detail is moving separately from the payment. BPR-02 782 Total Actual Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount BPR02 specifies the payment amount. Usage notes Use BPR02 for the total payment amount for this 835. The total payment amount for this 835 cannot exceed eleven characters, including decimals (99999999.99). Although the value can be zero, the 835 cannot be issued for less than zero dollars. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). BPR-03 478 Credit or Debit Flag Code Identifier (ID) Required Code indicating whether amount is a credit or debit 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 11 124 C Credit Use this code to indicate a credit to the provider's account and a debit to the payer's account, initiated by the payer. In the case of an EFT, no additional action is required of the provider. Also use this code when a check is issued for the payment. D Debit Use this code to indicate a debit to the payer's account and a credit to the provider's account, initiated by the provider at the instruction of the payer. Extreme caution must be used when using Debit transactions. Contact your VAB for information about debit transactions. The rest of this segment and document assumes that a credit payment is being used. BPR-04 591 Payment Method Code Identifier (ID) Required Code identifying the method for the movement of payment instructions ACH Automated Clearing House (ACH) Use this code to move money electronically through the ACH, or to notify the provider that an ACH transfer was requested. When this code is used, see BPR05 through BPR15 for additional requirements. CHK Check Use this code to indicate that a check has been issued for payment. BPR-05 812 Payment Format Code Identifier (ID) Optional Code identifying the payment format to be used CCP Cash Concentration Disbursement plus Addenda (CCD ) (ACH) Use the CCD format to move money and up to 80 characters of data, enough to reassociate dollars and data when the dollars are sent through the ACH and the data is sent on a separate path. The addenda must contain a copy of the TRN segment. BPR-06 506 Depository Financial Institution (DFI) Identification Number Qualifier Optional Identifier (ID) Code identifying the type of identification number of Depository Financial Institution (DFI) When using this transaction set to initiate a payment, all or some of BPR06 through BPR16 may be required, depending on the conventions of the specific financial channel being used. BPR06 and BPR07 relate to the originating depository financial institution (ODFI). Usage notes BPR06 through BPR09 relate to the originating financial institution and the originator's account (payer). 01 ABA Transit Routing Number Including Check Digits (9 digits) The ABA transit routing number is a unique number identifying every bank in the United States. BPR-07 507 Sender DFI Identifier Min 3 Max 12 String (AN) Optional Depository Financial Institution (DFI) identification number Usage notes 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 12 124 Use this number for the identifying number of the financial institution sending the transaction into the applicable network. SHP s Number BPR-08 569 Account Number Qualifier Identifier (ID) Optional Code indicating the type of account BPR08 is a code identifying the type of bank account or other financial asset. Usage notes Use this code to identify the type of account in BPR09. DA Demand Deposit BPR-09 508 Sender Bank Account Number Min 1 Max | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_2 |
Number Qualifier Identifier (ID) Optional Code indicating the type of account BPR08 is a code identifying the type of bank account or other financial asset. Usage notes Use this code to identify the type of account in BPR09. DA Demand Deposit BPR-09 508 Sender Bank Account Number Min 1 Max 35 String (AN) Optional Account number assigned BPR09 is the account of the company originating the payment. This account may be debited or credited depending on the type of payment order. Usage notes Use this number for the originator's account number at the financial institution. SHP s Account Number BPR-10 509 Payer Identifier String (AN) Optional A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification. BPR10 shall be mutually established between the originating depository financial institution (ODFI) and the company originating the payment. 1391572880 BPR-11 510 Originating Company Supplemental Code Min 9 Max 9 String (AN) Optional A code defined between the originating company and the originating depository financial institution (ODFI) that uniquely identifies the company initiating the transfer instructions Usage notes Use this code to further identify the payer by division or region. The element must be left justified and space filled to meet the minimum element size requirements. If used, this code must be identical to TRN04, excluding trailing spaces. BPR-12 506 Depository Financial Institution (DFI) Identification Number Qualifier Optional Identifier (ID) Code identifying the type of identification number of Depository Financial Institution (DFI) BPR12 and BPR13 relate to the receiving depository financial institution (RDFI). Usage notes BPR12 through BPR15 relate to the receiving financial institution and the receiver's account. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 13 124 01 ABA Transit Routing Number Including Check Digits (9 digits) The ABA transit routing number is a unique number identifying every bank in the United States. BPR-13 507 Receiver or Provider Bank ID Number Min 3 Max 12 String (AN) Optional Depository Financial Institution (DFI) identification number Usage notes Use this number for the identifying number of the financial institution receiving the transaction from the applicable network. Routing Number of Receiver or Provider Bank BPR-14 569 Account Number Qualifier Identifier (ID) Optional Code indicating the type of account BPR14 is a code identifying the type of bank account or other financial asset. Usage notes Use this code to identify the type of account in BPR15. DA Demand Deposit BPR-15 508 Receiver or Provider Account Number Min 1 Max 35 String (AN) Optional Account number assigned BPR15 is the account number of the receiving company to be debited or credited with the payment order. Usage notes Use this number for the receiver's account number at the financial institution. Provider Account Number BPR-16 373 Check Issue or EFT Effective Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year BPR16 is the date the originating company intends for the transaction to be settled (i.e., Payment Effective Date). Usage notes Use this for the effective entry date. If BPR04 is ACH, this is the date that the money moves from the payer and is available to the payee. If BPR04 is CHK, this is the check issuance date. If BPR04 is FWT, this is the date that the payer anticipates the money to move. As long as the effective date is a business day, this is the settlement date. If BPR04 is NON', enter the date of the 835. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 14 124 TRN 0400 Heading TRN Reassociation Trace Number To uniquely identify a transaction to an application Usage notes This segment's purpose is to uniquely identify this transaction set and to aid in reassociating payments and remittances that have been separated. Example TRN 1 XXXX 1391572880 XX Max use 1 Required TRN-01 481 Trace Type Code Identifier (ID) Required Code identifying which transaction is being referenced 1 Current Transaction Trace Numbers TRN-02 127 Check or EFT Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TRN02 provides unique identification for the transaction. Usage notes This number must be unique within the sender receiver relationship. The number is assigned by the sender. If payment is made by check, this must be the check number. If payment is made by EFT, this must be the EFT reference number. If this is a non- payment 835, this must be a unique remittance advice identification number. See 1.10.2.3, Reassociation of Dollars and Data, for additional information. Remittance Advice Number TRN-03 509 Payer Identifier String (AN) Required A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification. TRN03 identifies an organization. Usage notes This must be a 1 followed by the payer's EIN (or TIN). 1391572880 TRN-04 127 Originating Company Supplemental Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TRN04 identifies a further subdivision within the organization. Usage notes If both TRN04 and BPR11 are used, they must be identical, excluding trailing spaces. Since BPR11 has a min max value of 9 9, whenever both are used, this element is restricted to a maximum size of 9. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 15 124 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 16 124 CUR 0500 Heading CUR Foreign Currency Information To specify the currency (dollars, pounds, francs, etc.) used in a transaction Usage notes When the CUR segment is not present, the currency of payment is defined as US dollars. Required when the payment is | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_3 |
app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 16 124 CUR 0500 Heading CUR Foreign Currency Information To specify the currency (dollars, pounds, francs, etc.) used in a transaction Usage notes When the CUR segment is not present, the currency of payment is defined as US dollars. Required when the payment is not being made in US dollars. If not required by this implementation guide, do not send. Example CUR PR XXX Max use 1 Optional CUR-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer CUR-02 100 Currency Code Min 3 Max 3 Identifier (ID) Required Code (Standard ISO) for country in whose currency the charges are specified Usage notes This is the currency code for the payment currency. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 17 124 REF 0600 Heading REF Receiver Identification To specify identifying information Usage notes This is the business identification information for the transaction receiver. This may be different than the EDI address or identifier of the receiver. This is the initial receiver of the transaction. This information must not be updated if the transaction is routed through multiple intermediaries, such as clearinghouses, before reaching the payee. Required when the receiver of the transaction is other than the payee (e.g., a clearinghouse or billing service). If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example REF EV XX Variants (all may be used) REF Version Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EV Receiver Identification Number REF-02 127 Receiver Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 18 124 REF 0600 Heading REF Version Identification To specify identifying information Usage notes Update this reference number whenever a change in the version or release number affects the 835. (This is not the ANSI ASCX12 version number as reported in the GS segment.) Required when necessary to report the version number of the adjudication system that generated the claim payments in order for the payer to resolve customer service questions from the payee. If not required by this implementation guide, do not send. Example REF F2 XXX Variants (all may be used) REF Receiver Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F2 Version Code - Local REF-02 127 Version Identification Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 19 124 DTM 0700 Heading DTM Production Date To specify pertinent dates and times Usage notes If your adjudication cycle completed on Thursday and your 835 is produced on Saturday, you are required to populate this segment with Thursday's date. Required when the cut off date of the adjudication system remittance run is different from the date of the 835 as identified in the related GS04 element. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example DTM 405 20250130 Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 405 Production DTM-02 373 Production Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes Report the end date for the adjudication production cycle for claims included in this 835. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 20 124 1000A Payer Identification Loop Max 1 Required Variants (all may be used) Payee Identification Loop N1 0800 Heading Payer Identification Loop N1 Payer Identification To identify a party by type of organization, name, and code Usage notes Use this N1 loop to provide the name address information for the payer. The payer's secondary identifying reference number is provided in N104, if necessary. Example N1 PR SECURITY HEALTH PLAN XV XXXXX If either Identification Code Qualifier (N1-03) or Payer Identifier (N1-04) is present, then the other is required Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer N1-02 93 Payer Name String (AN) Required Free-form name ADVOCARE FAMILY HEALTH CENTER MEDICAID SECURITY HEALTH PLAN TPA N1-03 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). N1-04 67 Payer Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 21 124 N3 1000 Heading Payer Identification Loop N3 Payer Address To specify the location of the named party Example N3 XX XXXX Max use 1 Required N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_4 |
named party Example N3 XX XXXX Max use 1 Required N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 22 124 N4 1100 Heading Payer Identification Loop N4 Payer City, State, ZIP Code To specify the geographic place of the named party Example N4 XXX XX XXXXX XX Only one of Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Payer State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 23 124 REF 1200 Heading Payer Identification Loop REF Additional Payer Identification To specify identifying information Usage notes The ID available in the TRN and N1 segments must be used before using the REF segment. Required when additional payer identification numbers beyond those in the TRN and Payer N1 segments are needed. If not required by this implementation guide, may be sent at sender's discretion, but cannot be required by the receiver. Example REF HI XXXXXX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number For Medicare carriers or intermediaries, use this qualifier for the Medicare carrier or intermediary ID number. For Blue Cross and Blue Shield Plans, use this qualifier for the Blue Cross Blue Shield association plan code. EO Submitter Identification Number This is required when the original transaction sender is not the payer or is identified by an identifier other than those already provided. This is not updated by third parties between the payer and the payee. An example of a use for this qualifier is when identifying a clearinghouse that created the 835 when the health plan sent a proprietary format to the clearinghouse. HI Health Industry Number (HIN) NF National Association of Insurance Commissioners (NAIC) Code This is the preferred value when identifying the payer. REF-02 127 Additional Payer Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 24 124 PER 1300 Heading Payer Identification Loop PER Payer Business Contact Information To identify a person or office to whom administrative communications should be directed Usage notes When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800) 555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number. Required when there is a business contact area that would apply to this remittance and all the claims. If not required by this implementation guide, do not send. Example PER CX PROVIDER RELATIONS TE 8005481224 FX X EX X X Variants (all may be used) PER Payer Technical Contact Information PER Payer WEB Site If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required If either Communication Number Qualifier (PER-05) or Payer Contact Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Payer Contact Name String (AN) Optional Free-form name Usage notes Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). PROVIDER RELATIONS PER-03 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number TE Telephone 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 25 124 PER-04 364 Payer Contact Communication Number String (AN) Optional Complete communications number including country or area code when applicable 8005481224 PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_5 |
Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 26 124 PER 1300 Heading Payer Identification Loop PER Payer Technical Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required to report technical contact information for this remittance advice. Example PER BL XXXXXX EM XXXXX UR XX EX XXX Variants (all may be used) PER Payer Business Contact Information PER Payer WEB Site If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required If either Communication Number Qualifier (PER-05) or Payer Technical Contact Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required Max use 1 Required PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named BL Technical Department PER-02 93 Payer Technical Contact Name Min 1 Max 60 String (AN) Optional Free-form name Usage notes Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). PER-03 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail TE Telephone Recommended UR Uniform Resource Locator (URL) Use only when there is no central telephone number for the payer entity. PER-04 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 27 124 PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is theextension for the preceding communicationscontact number. FX Facsimile TE Telephone UR Uniform Resource Locator (URL) PER-06 364 Payer Technical Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is theextension for the preceding communicationscontact number. FX Facsimile UR Uniform Resource Locator (URL) PER-08 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 28 124 1000A Payer Identification Loop end PER 1300 Heading Payer Identification Loop PER Payer WEB Site To identify a person or office to whom administrative communications should be directed Usage notes Required when any 2110 loop Healthcare Policy REF Segment is used. If not required by this implementation guide, do not send. This is a direct link to the policy location of the un-secure website. Example PER IC UR XX Variants (all may be used) PER Payer Business Contact Information PER Payer Technical Contact Information Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number UR Uniform Resource Locator (URL) PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable Usage notes This is the payer's WEB site URL where providers can find policy and other related information. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 29 124 1000B Payee Identification Loop Max 1 Required Variants (all may be used) Payer Identification Loop N1 0800 Heading Payee Identification Loop N1 Payee Identification To identify a party by type of organization, name, and code Usage notes Use this N1 loop to provide the name address information of the payee. The identifying reference number is provided in N104. Example N1 PE XXX FI XX Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PE Payee N1-02 93 Payee Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Required if provider is not mandated by NPI. For individual providers as payees, use this qualifier to represent the Social Security Number. XX Centers for Medicare and Medicaid Services National Provider Identifier This is REQUIRED when the National Provider Identifier is mandated for use and the payee is a covered health care provider under the mandate. N1-04 67 Payee Identification Code Min 2 Max 80 String (AN) Required Code identifying a party or other code This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 30 124 | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_6 |
identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 30 124 N3 1000 Heading Payee Identification Loop N3 Payee Address To specify the location of the named party Usage notes Required when the sender needs to communicate the payee address to a transaction receiver, e.g., a VAN or a clearinghouse. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example N3 XXXX XXXXX Max use 1 Optional N3-01 166 Payee Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payee Address Line Min 1 Max 55 String (AN) Optional Address information 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 31 124 N4 1100 Heading Payee Identification Loop N4 Payee City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the sender needs to communicate the payee address to a transaction receiver, e.g., a VAN or a clearinghouse. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example N4 XXXXX XX XXXXXXX XX Only one of Payee State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Payee City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Payee State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Payee Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 32 124 REF 1200 Heading Payee Identification Loop REF Payee Additional Identification To specify identifying information Usage notes Required when identification of the payee is dependent upon an identification number beyond that supplied in the N1 segment. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example REF PQ XXX Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PQ Payee Identification TJ Federal Taxpayer's Identification Number This information must be in the N1 segment unless the National Provider ID or the Health Plan Identifier (HPID) or Other Entity Identifier (OEID) was used in N104. For individual providers as payees, use this number to represent the Social Security Number. TJ also represents the Employer Identification Number (EIN). According to the IRS, TIN and EIN can be used interchangeably. REF-02 127 Additional Payee Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 33 124 RDM 1400 Heading Payee Identification Loop RDM Remittance Delivery Method To identify remittance delivery when remittance is separate from payment Usage notes Required when BPR01 U or X; and the remittance is to be sent separately from the payment. The payer is responsible to provide the bank with the instructions on how to deliver the remittance information, if not required by this implementation guide, do not send. Payer should coordinate this process with their Originating Depository Financial Institution (ODFI). Example RDM BM XXXXX XXX Max use 1 Optional RDM-01 756 Report Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent BM By Mail When used, RDM02 must be used. When BM is used, the remittance information will be mailed to the payee at the address identified in this 1000B loop. EM E-Mail Use with encrypted e-mail. FT File Transfer Use with FTP communications. OL On-Line Use with secured hosted or other electronic delivery. RDM-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name RDM02 is used to contain the name of a third party processor if needed, who would be the first recipient of the remittance. Usage notes When BM is used, the remittance information will be mailed to the attention of this person at the payee's address identified in this 1000B loop. RDM-03 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable RDM03 contains the operative communication number for the delivery method specified in RDM01 (i.e. fax phone number and mail address). Usage notes 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 34 124 1000B Payee Identification Loop end Heading end Contains URL web address or e-mail address. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 35 124 Detail 2000 Header Number Loop Max 1 Optional LX 0030 Detail Header Number Loop LX Header Number To reference a | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_7 |
e-mail address. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 35 124 Detail 2000 Header Number Loop Max 1 Optional LX 0030 Detail Header Number Loop LX Header Number To reference a line number in a transaction set Usage notes Required when claim service information is being provided in the transaction. If not required by this implementation guide, do not send. The purpose of LX01 is to provide an identification of a particular grouping of claims for sorting purposes. In the event that claim service information must be sorted, the LX segment must precede each series of claim level and service level segments. This number is intended to be unique within each transaction. Example LX 0 Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 36 124 TS3 0050 Detail Header Number Loop TS3 Provider Summary Information To supply provider-level control information Usage notes TS301 identifies the subsidiary provider. The remaining mandatory elements (TS302 through TS305) must be valid with appropriate data, as defined by the TS3 segment. Only Medicare Part A uses data elements TS313, TS315, TS317, TS318 and TS320 through TS324. Each monetary amount element is for that provider for this facility type code for loop 2000. Required for Medicare Part A or when payers and payees outside the Medicare Part A community need to identify provider subsidiaries whose remittance information is contained in the 835 transactions transmitted to a single provider entity i.e., the corporate office of a hospital chain. If not required by this implementation guide, do not send. Example TS3 X XX 20250130 0 00000000000 000000000 0 0000000 000000000 0000000000000 00 0000000 0 0000000000 00000000000 000 Max use 1 Optional TS3-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TS301 is the provider number. Usage notes This is the provider number. TS3-02 1331 Facility Type Code Min 1 Max 2 String (AN) Required Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. Usage notes When reporting a TS3 segment for professional claims and the claims are not all for the same place of service, report a place of service of 11 (Office) as the default value. When reporting a TS3 segment for pharmaceutical claims and the claims are not all for the same place of service, report a place of service of 99 (Other unlisted facility) as the default value. TS3-03 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year TS303 is the last day of the provider's fiscal year. Usage notes 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 37 124 Use this date for the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known, use December 31st of the current year. TS3-04 380 Total Claim Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity TS304 is the total number of claims. Usage notes This is the total number of claims. TS3-05 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount TS305 is the total of reported charges. Usage notes This is the total reported charges for all claims. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all 782 elements. TS3-13 782 Total MSP Payer Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS313 is the total Medicare Secondary Payer (MSP) primary payer amount. Usage notes See TR3 note 3. TS3-15 782 Total Non-Lab Charge Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS315 is the summary of non-lab charges. Usage notes See TR3 note 3. TS3-17 782 Total HCPCS Reported Charge Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS317 is the Health Care Financing Administration Common Procedural Coding System (HCPCS) reported charges. Usage notes See TR3 note 3. TS3-18 782 Total HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 38 124 Monetary amount TS318 is the total Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes See TR3 note 3. TS3-20 782 Total Professional Component Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS320 is the total professional component amount. Usage notes The professional component amount must also be reported in the CAS segment with a Claim Adjustment Reason Code value of 89. See TR3 note 3. TS3-21 782 Total MSP Patient Liability Met Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS321 is the total Medicare Secondary Payer (MSP) patient liability met. Usage notes See TR3 note 3. TS3-22 782 Total Patient Reimbursement Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS322 is the total patient reimbursement. Usage notes See TR3 note 3. TS3-23 380 Total PIP Claim Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS323 is the total periodic interim payment (PIP) number of claims. Usage notes See TR3 note 3. TS3-24 782 Total PIP Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS324 is total periodic interim payment (PIP) adjustment. Usage notes 1 29 25, 8:52 | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_8 |
value of quantity TS323 is the total periodic interim payment (PIP) number of claims. Usage notes See TR3 note 3. TS3-24 782 Total PIP Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS324 is total periodic interim payment (PIP) adjustment. Usage notes 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 39 124 See TR3 note 3. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 40 124 TS2 0070 Detail Header Number Loop TS2 Provider Supplemental Summary Information To provide supplemental summary control information by provider fiscal year and bill type Usage notes This segment provides summary information specific to an iteration of the LX loop (Table 2). Each element represents the total value for the provider bill type combination in this loop 2000 iteration. Required for Medicare Part A. If not required by this implementation guide, do not send. Example TS2 00000000 000000 00000000000000 000000000 0000 000000000 000 0000000000000 000000000000 00000000 00 000000 00 0000000000000 00000000 0000000 00000 0 00 000000000000 0000000000000 000000000000000 Max use 1 Optional TS2-01 782 Total DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS201 is the total diagnosis related group (DRG) amount. Usage notes This includes: operating federal-specific amount, operating hospital-specific amount, operating Indirect Medical Education amount, and operating Disproportionate Share Hospital amount. It does not include any operating outlier amount. See TR3 note 2. TS2-02 782 Total Federal Specific Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS202 is the total federal specific amount. Usage notes See TR3 note 2. TS2-03 782 Total Hospital Specific Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS203 is the total hospital specific amount. Usage notes See TR3 note 2. TS2-04 782 Total Disproportionate Share Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS204 is the total disproportionate share amount. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 41 124 Usage notes See TR3 note 2. TS2-05 782 Total Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS205 is the total capital amount. Usage notes This includes: capital federal-specfic amount, hospital federal-specfic amount, hold harmless amount, Indirect Medical Education amount, Disproportionate Share Hospital amount, and the exception amount. It does not include any capital outlier amount. See TR3 note 2. TS2-06 782 Total Indirect Medical Education Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS206 is the total indirect medical education amount. Usage notes See TR3 note 2. TS2-07 380 Total Outlier Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS207 is the total number of outlier days. Usage notes See TR3 note 2. TS2-08 782 Total Day Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS208 is the total day outlier amount. Usage notes See TR3 note 2. TS2-09 782 Total Cost Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS209 is the total cost outlier amount. Usage notes See TR3 note 2. TS2-10 380 Average DRG Length of Stay Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 42 124 TS210 is the diagnosis related group (DRG) average length of stay. Usage notes See TR3 note 2. TS2-11 380 Total Discharge Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS211 is the total number of discharges. Usage notes This is the discharge count produced by PPS PRICER SOFTWARE. See TR3 note 2. TS2-12 380 Total Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS212 is the total number of cost report days. Usage notes See TR3 note 2. TS2-13 380 Total Covered Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS213 is the total number of covered days. Usage notes See TR3 note 2. TS2-14 380 Total Noncovered Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS214 is total number of non-covered days. Usage notes See TR3 note 2. TS2-15 782 Total MSP Pass-Through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS215 is the total Medicare Secondary Payer (MSP) pass- through amount calculated for a non-Medicare payer. Usage notes See TR3 note 2. TS2-16 380 Average DRG weight Min 1 Max 15 Decimal number (R) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 43 124 Numeric value of quantity TS216 is the average diagnosis-related group (DRG) weight. Usage notes See TR3 note 2. TS2-17 782 Total PPS Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS217 is the total prospective payment system (PPS) capital, federal-specific portion, diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. TS2-18 782 Total PPS Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS218 is the total prospective payment system (PPS) capital, hospital-specific portion, diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. TS2-19 782 Total PPS DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS219 is the total prospective payment system (PPS) disproportionate share, hospital diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 44 124 2100 Claim Payment Information Loop Max 1 Required CLP 0100 Detail Header Number Loop Claim Payment Information Loop CLP Claim Payment Information To supply | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_9 |
25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 44 124 2100 Claim Payment Information Loop Max 1 Required CLP 0100 Detail Header Number Loop Claim Payment Information Loop CLP Claim Payment Information To supply information common to all services of a claim Usage notes For CLP segment occurrence limitations, see section 1.3.2, Other Usage Limitations. Example CLP XXXX 20 00000000000 000000000000 0 MB XXX X X X XXXX 000000000000 000 Max use 1 Required CLP-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment Usage notes Use this number for the patient control number assigned by the provider. If the patient control number is not present on the incoming claim, enter a single zero. The value in CLP01 must be identical to any value received as a Claim Submitter's Identifier on the original claim (CLM01 of the ANSI ASC X12 837, if applicable). This data element is the primary key for posting the remittance information into the provider's database. In the case of pharmacy claims, this is the prescription reference number (field 402-02 in the NCPDP 5.1 format). CLP-02 1029 Claim Status Code Identifier (ID) Required Code identifying the status of an entire claim as assigned by the payor, claim review organization or repricing organization Usage notes To determine the full claim status reference Claim adjustment reason codes in the CAS segment in conjunction with this claim status code. 1 Processed as Primary Use this code if the claim was adjudicated by the current payer as primary regardless of whether any part of the claim was paid. 2 Processed as Secondary Use this code if the claim was adjudicated by the current payer as secondary regardless of whether any part of the claim was paid. 3 Processed as Tertiary Use this code if the claim was adjudicated by the current payer as tertiary (or subsequent) regardless of whether any part of the claim was paid. 4 Denied Usage of this code would apply if the Patient Subscriber is not recognized, and the claim was not forwarded to another payer. 19 Processed as Primary, Forwarded to Additional Payer(s) When this code is used, the Crossover Carrier Name NM1 segment is required. 20 Processed as Secondary, Forwarded to Additional Payer(s) 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 45 124 When this code is used, the Crossover Carrier Name NM1 segment is required. 21 Processed as Tertiary, Forwarded to Additional Payer(s) When this code is used, the Crossover Carrier Name NM1 segment is required. 22 Reversal of Previous Payment See section 1.10.2.8 for usage information. 23 Not Our Claim, Forwarded to Additional Payer(s) Usage of this code would apply if the patient subscriber is not recognized, the claim was not adjudicated by the payer, but other payers are known and the claim has been forwarded to another payer. When this code is used, the Crossover Carrier Name NM1 segment is required. 25 Predetermination Pricing Only - No Payment CLP-03 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLP03 is the amount of submitted charges this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. Use this monetary amount for the submitted charges for this claim. The amount can be positive, zero or negative. An example of a situation with a negative charge is a reversal claim. See section 1.10.2.8 for additional information. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CLP-04 782 Claim Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLP04 is the amount paid this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. See section 1.10.2.9 for information about interest considerations. Use this monetary amount for the amount paid for this claim. It can be positive, zero or negative, but the value in BPR02 may not be negative. CLP-05 782 Patient Responsibility Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CLP05 is the patient responsibility amount. Usage notes Amounts in CLP05 must have supporting adjustments reflected in CAS segments at the 2100 (CLP) or 2110 (SVC) loop level with a Claim Adjustment Group (CAS01) code of PR (Patient Responsibility). Use this monetary amount for the payer's statement of the patient responsibility amount for this claim, which can include such items as deductible, non-covered services, co-pay and co-insurance. This is not used for reversals. See section 1.10.2.8, Reversals and Corrections, for additional information. CLP-06 1032 Claim Filing Indicator Code Identifier (ID) Required 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 46 124 Code identifying type of claim Usage notes For many providers to electronically post the 835 remittance data to their patient accounting systems without human intervention, a unique, provider-specific insurance plan code is needed. This code allows the provider to separately identify and manage the different product lines or contractual arrangements between the payer and the provider. Because most payers maintain the same Originating Company Identifier in the TRN03 or BPR10 for all product lines or contractual relationships, the CLP06 is used by the provider as a table pointer in combination with the TRN03 or BPR10 to identify the unique, provider-specific insurance plan code needed to post the payment without human intervention. The value should mirror the value received in the original claim (2- 005 SBR09 of the 837), if applicable, or provide the value as assigned or edited by the payer. For example the BL from the SBR09 in the 837 would be returned as 12, 13, 15, in the 835 when more details are known. The 837 SBR09 code CI (Commercial Insurance) is generic, | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_10 |
of the 837), if applicable, or provide the value as assigned or edited by the payer. For example the BL from the SBR09 in the 837 would be returned as 12, 13, 15, in the 835 when more details are known. The 837 SBR09 code CI (Commercial Insurance) is generic, if through adjudication the specific type of plan is obtained a more specific code must be returned in the 835. The 837 and 835 transaction code lists for this element are not identical by design. There are some business differences between the two transactions. When a code from the 837 is not available in the 835 another valid code from the 835 must be assigned by the payer. 12 Preferred Provider Organization (PPO) This code is also used for Blue Cross Blue Shield participating provider arrangements. 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance This code is also used for Blue Cross Blue Shield non-participating provider arrangements. 16 Health Maintenance Organization (HMO) Medicare Risk 17 Dental Maintenance Organization AM Automobile Medical CH Champus DS Disability HM Health Maintenance Organization LM Liability Medical MA Medicare Part A MB Medicare Part B MC Medicaid OF Other Federal Program Use this code for the Black Lung Program. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined CLP-07 127 Payer Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CLP07 is the payer's internal control number. Usage notes 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 47 124 Use this number for the payer's internal control number. This number must apply to the entire claim. CLP-08 1331 Facility Type Code Min 1 Max 2 String (AN) Optional Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. Usage notes Since professional or dental claims can have different place of service codes for services within a single claim, default to the place of service of the first service line when the service lines are not all for the same place of service. This number was received in CLM05-1 of the 837 claim. CLP-09 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Optional Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type Usage notes This number was received in CLM05-3 of the 837 Claim. CLP-11 1354 Diagnosis Related Group (DRG) Code Min 1 Max 4 Identifier (ID) Optional Code indicating a patient's diagnosis group based on a patient's illness, diseases, and medical problems CLP-12 380 Diagnosis Related Group (DRG) Weight Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CLP12 is the diagnosis-related group (DRG) weight. Usage notes This is the adjudicated DRG Weight. CLP-13 954 Discharge Fraction Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0 through 100 ) CLP13 is the discharge fraction. Usage notes This is the adjudicated discharge fraction. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 48 124 CAS 0200 Detail Header Number Loop Claim Payment Information Loop CAS Claim Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Payers must use this CAS segment to report claim level adjustments that cause the amount paid to differ from the amount originally charged. See 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. See the SVC TR3 Note 1 for details about per diem adjustments. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment must be the first non-zero adjustment and is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Required when dollar amounts and or quantities are being adjusted at the claim level. If not required by this implementation guide, do not send. Example CAS PR X 00000000000 00000000000 XXX 00000 000000 000000 X 000000000000000 0000000000 XXX 0000 0000 000 XXX 00000 000000000 XXXX 00000000000000 00000 0 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS- 07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_11 |
then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 49 124 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer payee contractual agreement or a regulatory requirement resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PI Payor Initiated Reductions Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments). PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the claim level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes See section 1.10.2.4.1 for additional information. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 50 124 A positive value decreases the covered days, and a negative number increases the covered days. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 51 124 Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 52 124 Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 53 124 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Corrected Patient Insured Name To supply the full name of an individual or organizational entity Usage notes Since the patient is always the insured for Medicare and Medicaid, this segment always provides corrected patient information for Medicare and Medicaid. For other carriers, this will always be the corrected insured information. Required when needed to provide corrected information about the patient or insured. If not | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_12 |
entity Usage notes Since the patient is always the insured for Medicare and Medicaid, this segment always provides corrected patient information for Medicare and Medicaid. For other carriers, this will always be the corrected insured information. Required when needed to provide corrected information about the patient or insured. If not required by this implementation guide, do not send. Example NM1 74 2 XXXXX X X XXXXXX C XX Variants (all may be used) NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured Name NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Corrected Insured Identification Indicator (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 74 Corrected Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Corrected Patient or Insured Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Corrected Patient or Insured First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Corrected Patient or Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 54 124 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Corrected Patient or Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) C Insured's Changed Unique Identification Number NM1-09 67 Corrected Insured Identification Indicator Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 55 124 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Corrected Priority Payer Name To supply the full name of an individual or organizational entity Usage notes Provide any reference numbers in NM109. Use of this segment identifies the priority payer. Do not use this segment when the Crossover Carrier NM1 segment is used. Required when current payer believes that another payer has priority for making a payment and the claim is not being automatically transferred to that payer. If not required by this implementation guide, do not send. Example NM1 PR 2 XXXXX PP XXX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Crossover Carrier Name NM1 Insured Name NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Corrected Priority Payer Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) AD Blue Cross Blue Shield Association Plan Code FI Federal Taxpayer's Identification Number NI National Association of Insurance Commissioners (NAIC) Identification This is the preferred ID unless XV is used. PI Payor Identification PP Pharmacy Processor Number XV Centers for Medicare and Medicaid Services PlanID 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 56 124 Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used. NM1-09 67 Corrected Priority Payer Identification Number Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 57 124 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Crossover Carrier Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the crossover carrier. Provide any reference numbers in NM109. The crossover carrier is defined as any payer to which the claim is transferred for further payment after being finalized by the current payer. Required when the claim is transferred to another carrier or coverage (CLP02 equals 19, 20, 21 or 23). If not required by this implementation guide, do not send. Example NM1 TT 2 XXXXX PP XXX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Corrected Priority Payer Name NM1 Insured Name NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual TT Transfer To NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Crossover Carrier Name Min 1 Max 60 String (AN) Required Individual last name or organizational name Usage notes Name of the crossover carrier associated with this claim. NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) AD Blue Cross Blue Shield Association Plan Code FI Federal Taxpayer's Identification Number NI National Association of Insurance Commissioners (NAIC) Identification This is the preferred ID unless XV is used. PI Payor Identification 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 58 124 PP Pharmacy Processor Number XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_13 |
XV is used. PI Payor Identification 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 58 124 PP Pharmacy Processor Number XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used. NM1-09 67 Crossover Carrier Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 59 124 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Insured Name To supply the full name of an individual or organizational entity Usage notes In the case of Medicare and Medicaid, the insured patient is always the subscriber and this segment is not used. Required when the original claim reported the insured or subscriber (for example 837 2010BA loop Subscriber Name NM1 Segment) that is different from the patient. If not required by this implementation guide, do not send. This segment contains the same information as reported on the claim (for example 837 2010BA loop Subscriber Name NM1 Segment when the patient was reported in the 2010CA loop Patient Name NM1 Segment). Example NM1 IL 1 XXXXXX XXXXXX X XXX MI XX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Subscriber Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 60 124 Individual middle name or initial Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes For example, use when necessary to differentiate between a Junior and Senior under the same contract. NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) MI Member Identification Number The code MI is intended to identify that the subscriber's identification number as assigned by the payer will be conveyed in NM109. Payers use different terminology to convey the same number, therefore, the 835 workgroup recommends using MI (Member Identification number) to convey the same categories of numbers as represented in the 837 IGs for the inbound claims. NM1-09 67 Subscriber Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes Security Health Plan Member ID 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 61 124 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes This is the name and ID number of the other subscriber when a corrected priority payer has been identified. When used, either the name or ID must be supplied. Required when a corrected priority payer has been identified in another NM1 segment AND the name or ID of the other subscriber is known. If not required by this implementation guide, do not send. Example NM1 GB 2 XXX XXX XXXXXX XXXXXX II XXX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured Name NM1 Patient Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Other Subscriber Identifier (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual GB Other Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Subscriber Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name Usage notes At least one of NM103 or NM109 must be present. NM1-04 1036 Other Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 62 124 Individual middle name or initial Usage notes When only one character is present this is assumed to be the middle initial. NM1-07 1039 Other Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Not Used when NM102 1. II Standard Unique Health Identifier for each Individual in the United States Use this code if mandated in a final Federal Rule. MI Member Identification Number Use this code when supplying the number used for identification of the subscriber in NM109. NM1-09 67 Other Subscriber Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes At least one of NM103 or NM109 must be present. 1 29 25, 8:52 PM Security Health | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_14 |
when supplying the number used for identification of the subscriber in NM109. NM1-09 67 Other Subscriber Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes At least one of NM103 or NM109 must be present. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 63 124 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Patient Name To supply the full name of an individual or organizational entity Usage notes Provide the patient's identification number in NM109. This segment must provide the information from the original claim. For example, when the claim is submitted as an ASC X12 837 transaction, this is the 2010CA loop NM1 Patient Name Segment unless not present on the original claim, then it is the 2010BA loop NM1 Subscriber name segment. The Corrected Patient Insured Name NM1 segment identifies the adjudicated Insured Name and ID information if different than what was submitted on the claim. Example NM1 QC 1 XX XXXXXX XXXX XXXX MI XXXXXX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured Name NM1 Other Subscriber Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Patient Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual QC Patient NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Patient Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Patient First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Patient Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 64 124 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Patient Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes An example of this is when a Junior and Senior are covered under the same subscriber. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) MI Member Identification Number NM1-09 67 Patient Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes Security Health Plan Member ID 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 65 124 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Service Provider Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the rendering provider. An identification number is provided in NM109. This information is provided to facilitate identification of the claim within a payee's system. Other providers (e.g., Referring provider, supervising provider) related to the claim but not directly related to the payment are not supported and are not necessary for claim identification. Required when the rendering provider is different from the payee. If not required by this implementation guide, do not send. Example NM1 82 1 XXXX XXX XXXXXX XXX XX XXXX Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured Name NM1 Other Subscriber Name NM1 Patient Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 66 124 Individual middle name or initial Usage notes If this data element is used and contains only one character, it represents the middle initial. NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) BD Blue Cross Provider Number BS Blue Shield Provider Number FI Federal Taxpayer's Identification Number This is the preferred ID until the National Provider ID is mandated and applicable. For individual providers as payees, use this qualifier to represent the Social Security Number. MC Medicaid Provider Number PC Provider Commercial Number SL State License Number UP Unique Physician Identification Number (UPIN) XX Centers for Medicare and Medicaid Services National Provider Identifier Required value if the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate. Otherwise, one of the other listed codes may be used. NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 67 124 MIA 0330 Detail Header Number Loop Claim Payment Information Loop MIA Inpatient Adjudication Information To provide claim-level data related to the adjudication of Medicare inpatient claims Usage notes When used outside of the Medicare and Medicaid community only MIA01, 05, 20, 21, 22 and 23 may be used. | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_15 |
67 124 MIA 0330 Detail Header Number Loop Claim Payment Information Loop MIA Inpatient Adjudication Information To provide claim-level data related to the adjudication of Medicare inpatient claims Usage notes When used outside of the Medicare and Medicaid community only MIA01, 05, 20, 21, 22 and 23 may be used. Either MIA or MOA may appear, but not both. This segment must not be used for covered days or lifetime reserve days. For covered or lifetime reserve days, use the Supplemental Claim Information Quantities Segment in the Claim Payment Loop. All situational quantities and or monetary amounts in this segment are required when the value of the item is different than zero. Required for all inpatient claims when there is a need to report Remittance Advice Remark Codes at the claim level or, the claim is paid by Medicare or Medicaid under the Prospective Payment System (PPS). If not required by this implementation guide, do not send. Example MIA 0000000 00000000000000 00000 000000000 XX 000 00000000000 0000000 0 000 0 00000000000000 000000 000000 00000000000000 00000 000000000 000000 0000 000 0000 000000 XXXXX XXX XX XXXXXX 000000000000 Max use 1 Optional MIA-01 380 Covered Days or Visits Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity MIA01 is the covered days. Usage notes Implementers utilizing the MIA segment always transmit the number zero. See the QTY segment at the claim level for covered days or visits count. MIA-02 782 PPS Operating Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA02 is the Prospective Payment System (PPS) Operating Outlier amount. Usage notes See TR3 note 4. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MIA-03 380 Lifetime Psychiatric Days Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA03 is the lifetime psychiatric days. MIA-04 782 Claim DRG Amount Min 1 Max 15 Decimal number (R) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 68 124 Monetary amount MIA04 is the Diagnosis Related Group (DRG) amount. MIA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA05 is the Claim Payment Remark Code. See Code Source 411. MIA-06 782 Claim Disproportionate Share Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA06 is the disproportionate share amount. MIA-07 782 Claim MSP Pass-through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA07 is the Medicare Secondary Payer (MSP) pass-through amount. MIA-08 782 Claim PPS Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA08 is the total Prospective Payment System (PPS) capital amount. MIA-09 782 PPS-Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 69 124 Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA19 is the professional component amount billed but not payable. MIA-20 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 70 124 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA20 is the Claim Payment Remark Code. See Code Source 411. MIA-21 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA21 is the Claim Payment Remark Code. See Code Source 411. MIA-22 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_16 |
Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 71 124 MOA 0350 Detail Header Number Loop Claim Payment Information Loop MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required for outpatient professional claims where there is a need to report a Remittance Advice Remark Code at the claim level or when the payer is Medicare or Medicaid and MOA01, 02, 08 or 09 are non-zero. If not required by this implementation guide, do not send. Either MIA or MOA may appear, but not both. All situational quantities and or monetary amounts in this segment are;required when the value of the item is different than zero. Example MOA 000 0000000 XX X XXXXX XXXX XXXX 000000000 0 Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0 through 100 ) MOA01 is the reimbursement rate. MOA-02 782 Claim HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 72 124 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 Claim ESRD Payment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 73 124 REF 0400 Detail Header Number Loop Claim Payment Information Loop REF Other Claim Related Identification To specify identifying information Usage notes Required when additional reference numbers specific to the claim in the CLP segment are provided to identify information used in the process of adjudicating this claim. If not required by this implementation guide, do not send. Example REF IG X Variants (all may be used) REF Rendering Provider Identification Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1L Group or Policy Number Use this code when conveying the Group Number in REF02. 1W Member Identification Number F8 Original Reference Number When this is a correction claim and CLP07 does not equal the CLP07 value from the original claim payment, one iteration of this REF segment using this qualifier is REQUIRED to identify the original claim CLP07 value in REF02. See section 1.10.2.8, Reversals and Corrections, for additional information. IG Insurance Policy Number Use this code when conveying the Policy Number in REF02. REF-02 127 Other Claim Related Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes For IL, Security Health Plan s carrier identifier For 1W, Member SSN For F8, Security Health Plan s Original Claim Identifier For IG, Security Health Plan s policy identifier 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 74 124 REF 0400 Detail Header Number Loop Claim Payment Information Loop REF Rendering Provider Identification To specify identifying information Usage notes The NM1 segment always contains the primary reference number. Required when additional rendering provider identification numbers not already reported in the Provider NM1 segment for this claim were submitted on the original claim and impacted adjudication. If not required by this implementation guide, do not send. Example REF LU XXXXX Variants (all may be used) REF Other Claim Related Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1A Blue Cross Provider Number 1B Blue Shield Provider Number 1C Medicare Provider Number 1D Medicaid Provider Number 1G Provider UPIN Number 1H CHAMPUS Identification Number 1J Facility ID Number D3 National Council for Prescription Drug Programs Pharmacy Number | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_17 |
(ID) Required Code qualifying the Reference Identification 0B State License Number 1A Blue Cross Provider Number 1B Blue Shield Provider Number 1C Medicare Provider Number 1D Medicaid Provider Number 1G Provider UPIN Number 1H CHAMPUS Identification Number 1J Facility ID Number D3 National Council for Prescription Drug Programs Pharmacy Number G2 Provider Commercial Number LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 75 124 DTM 0500 Detail Header Number Loop Claim Payment Information Loop DTM Claim Received Date To specify pertinent dates and times Usage notes Required whenever state or federal regulations or the provider contract mandate interest payment or prompt payment discounts based upon the receipt date of the claim by the payer. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example DTM 050 20250130 Variants (all may be used) DTM Coverage Expiration Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the date that the claim was received by the payer. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 76 124 DTM 0500 Detail Header Number Loop Claim Payment Information Loop DTM Coverage Expiration Date To specify pertinent dates and times Usage notes Required when payment is denied because of the expiration of coverage. If not required by this implementation guide, do not send. Example DTM 036 20250130 Variants (all may be used) DTM Claim Received Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 036 Expiration DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the expiration date of the patient's coverage. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 77 124 DTM 0500 Detail Header Number Loop Claim Payment Information Loop DTM Statement From or To Date To specify pertinent dates and times Usage notes Dates at the claim level apply to the entire claim, including all service lines. Dates at the service line level apply only to the service line where they appear. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. For retail pharmacy claims, the Claim Statement Period Start Date is equivalent to the prescription filled date. Required when the "Statement From or To Dates" are not supplied at the service (2110 loop) level. If not required by this implementation guide, may be provided at senders discretion, but cannot be required by the receiver. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM 232 20250130 Variants (all may be used) DTM Claim Received Date DTM Coverage Expiration Date Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 232 Claim Statement Period Start If the claim statement period start date is conveyed without a subsequent claim statement period end date, the end date is assumed to be the same as the start date. This date or code 233 is required when service level dates are not provided in the remittance advice. 233 Claim Statement Period End If a claim statement period end date is conveyed without a claim statement period start date, then the start date is assumed to be different from the end date but not conveyed at the payer's discretion. See the note on code 232. DTM-02 373 Claim Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 78 124 PER 0600 Detail Header Number Loop Claim Payment Information Loop PER Claim Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when there is a claim specific communications contact. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800)555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number. Example PER CX XXX FX XXX FX XXX EX XXXXX If either Communication Number Qualifier (PER-05) or Claim Contact Communications Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number Extension (PER-08) is present, then the other is required Max use 2 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_18 |
If either Communication Number Qualifier (PER-05) or Claim Contact Communications Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number Extension (PER-08) is present, then the other is required Max use 2 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Claim Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 79 124 EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Communication Number Extension Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 80 124 AMT 0620 Detail Header Number Loop Claim Payment Information Loop AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send receive one AMT for each applicable non-zero value. Do not report any zero values. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMT I 000000000000000 Max use 13 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount AU Coverage Amount Use this monetary amount to report the total covered charges. This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan. This excludes charges considered not covered (i.e. per day television or telephone charges) but includes reductions to payments of covered services (i.e. reductions for amounts over fee schedule and patient deductibles). I Interest See section 1.10.2.9 for additional information. AMT-02 782 Claim Supplemental Information Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 81 124 QTY 0640 Detail Header Number Loop Claim Payment Information Loop QTY Claim Supplemental Information Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send one QTY for each non-zero value. Do not report any zero values. Required when the value of a specific quantity identified by the QTY01 qualifier is non- zero. If not required by this implementation guide, do not send. Example QTY LE 00000 Max use 14 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity CA Covered - Actual CD Co-insured - Actual LA Life-time Reserve - Actual LE Life-time Reserve - Estimated NE Non-Covered - Estimated NR Not Replaced Blood Units OU Outlier Days PS Prescription VS Visits ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Claim Supplemental Information Quantity Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 82 124 2110 Service Payment Information Loop Max 999 Optional SVC 0700 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop SVC Service Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO78 25 ). See section 1.10.2.4.1 for additional information. See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information. Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send. Example SVC HC XXXX XX XX XX XX 000 000 XXXXX 00000000000 0 NU XXXX XX XX XX XX XXX 00 Max use 1 Required SVC-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_19 |
Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132). Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7. AD American Dental Association Codes ER Jurisdiction Specific Procedure and Supply Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. IV Home Infusion EDI Coalition (HIEC) Product Service Code 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 83 124 This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. N4 National Drug Code in 5-4-2 Format N6 National Health Related Item Code in 4-6 Format This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names National Health Related Item Code in 4-6 Format Codes as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. NU National Uniform Billing Committee (NUBC) UB92 Codes UI U.P.C. Consumer Package Code (1-5-5) This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names U.P.C. Consumer Package Code (1-5-5) Codes as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. WK Advanced Billing Concepts (ABC) Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used in transactions covered under HIPAA by parties registered in the pilot project and their trading partners. C003-02 234 Adjudicated Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 84 124 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. SVC-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC02 is the submitted service charge. Usage notes Use this monetary amount for the submitted service charge amount. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. SVC-03 782 Line Item Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC03 is the amount paid this service. Usage notes Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. See 1.10.2.1, Balancing, for additional information. SVC-04 234 National Uniform Billing Committee Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service SVC04 is the National Uniform Billing Committee Revenue Code. Usage notes If the original claim and adjudication only referenced an NUBC revenue code, that is supplied in SVC01 and this element is not used. SVC-05 380 Units of Service Paid Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC05 is the paid units of service. Usage notes If not present, the value is assumed to be one. SVC-06 C003 Composite Medical Procedure Identifier Max use 1 Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 85 124 To identify a medical procedure by its standardized codes and applicable modifiers - SVC06 is the original submitted medical procedure. Usage notes Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send. C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_20 |
provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send. C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7. AD American Dental Association Codes ER Jurisdiction Specific Procedure and Supply Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property Casualty claims encounters that are not covered under HIPAA. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes WK Advanced Billing Concepts (ABC) Codes This qualifier can only be used in transactions covere under HIPAA by parties registered in the pilot project and their trading partners. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 86 124 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVC-07 380 Original Units of Service Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC07 is the original submitted units of service. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 87 124 DTM 0800 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop DTM Service Date To specify pertinent dates and times Usage notes Dates at the service line level apply only to the service line where they appear. If used for inpatient claims and no service date was provided on the claim then report the through date from the claim level. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. Required when claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. For retail pharmacy claims, the service date is equivalent to the prescription filled date. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM 150 20250130 Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 150 Service Period Start This qualifier is required for reporting the beginning of multi-day services. If not required by this implementation guide, do not send. 151 Service Period End This qualifier is required for reporting the end of multi-day services. If not required by this implementation guide, do not send. 472 Service This qualifier is required to indicate a single day service. If not required by this implementation guide, do not send. DTM-02 373 Service Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 88 124 CAS 0900 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop CAS Service Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes An example of this level of CAS is the reduction for the part of the service charge that exceeds the usual and customary charge for the service. See sections 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02). If not required by this implementation | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_21 |
1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02). If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS PI XXX 000 0000000000 XXX 000000000 0 XXX 000 00000000000 0000000000 XX 000000000000 00000 XX 0 0000 00000000000000 XX 0000 0 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS- 07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 89 124 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer payee agreement or a regulatory requirement has resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PI Payor Initiated Reductions Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments). PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03 and CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 90 124 A positive number decreases paid units, and a negative value increases paid units. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 91 124 CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_22 |
8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 91 124 CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 92 124 Usage notes See CAS02. CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 93 124 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF HealthCare Policy Identification To specify identifying information Usage notes Required when; The payment is adjusted in accordance with the Payer's published Healthcare Policy Code list and A Claim Adjustment Reason Code identified by the notation, "refer to 835 Healthcare Policy identification segment", in the Claim Adjustment Reason Code List is present in a related CAS segment and The payer has a published enumerated healthcare policy code list available to healthcare providers via an un-secure public website and The payer wishes to supply this policy detail to reduce provider inquiries. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Healthcare Policy - A clinical statutory rule use to determine claim adjudication that cannot be explained by the sole use of a claim adjustment reason code in the CAS segment and Remittance Advise Remark code when appropriate. The term Healthcare Policy is intended to include Medical Review Policy, Dental Policy Review, Property and Casualty Policies, Workers Comp Policies and Pharmacy Policies for example Medicare LMRP's.( Local Medicare Review policies) and NCD (National Coverage Determinations). This policy segment must not be used to provide a proprietary explanation code or reason for adjustment. Supply the Healthcare policy identifier in REF02 as provided by the payer's published Healthcare policy code list. This policy code will be used to explain the policy used to process the claim which resulted in the adjusted payment. If this segment is used, the PER (Payer Web Site) segment is required to provide an un- secure WEB contact point where the provider can access the payer's enumerated, published healthcare policy. Example REF 0K X Variants (all may be used) REF Line Item Control Number REF Rendering Provider Information REF Service Identification Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0K Policy Form Identifying Number REF-02 127 Healthcare Policy Identification Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 94 124 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Line Item Control Number To specify identifying information Usage notes This is the Line Item Control Number submitted in the 837, which is utilized by the provider for tracking purposes. See section 1.10.2.11 and 1.10.2.14.1 for additional information on usage with split claims or services. Note - the value in REF02 can include alpha characters. Required when a Line Item Control Number was received on the original claim or when claim or service line splitting has occurred. If not required by this implementation guide, do not send. Example REF 6R X Variants (all may be used) REF HealthCare Policy Identification REF Rendering Provider Information REF Service Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 95 124 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Rendering Provider Information To specify identifying information Usage notes Required when the rendering provider for this service is different than the rendering provider applicable at the claim level. If not required by this implementation guide, do not send. Example REF HPI XXXXXX Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Service Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1A Blue Cross Provider Number 1B Blue Shield Provider Number 1C Medicare Provider Number 1D Medicaid Provider Number 1G Provider UPIN Number 1H CHAMPUS Identification Number 1J | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_23 |
Service Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1A Blue Cross Provider Number 1B Blue Shield Provider Number 1C Medicare Provider Number 1D Medicaid Provider Number 1G Provider UPIN Number 1H CHAMPUS Identification Number 1J Facility ID Number D3 National Council for Prescription Drug Programs Pharmacy Number G2 Provider Commercial Number HPI Centers for Medicare and Medicaid Services National Provider Identifier This qualifier is REQUIRED when the National Provider Identifier is mandated for use and the provider is a covered health care provider under that mandate. SY Social Security Number TJ Federal Taxpayer's Identification Number REF-02 127 Rendering Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 96 124 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Service Identification To specify identifying information Usage notes Required when related service specific reference identifiers were used in the process of adjudicating this service. If not required by this implementation guide, do not send. Example REF BB XXX Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Rendering Provider Information Max use 8 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification BB Authorization Number REF-02 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 97 124 AMT 1100 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop AMT Service Supplemental Amount To indicate the total monetary amount Usage notes This segment is used to convey information only. It is not part of the financial balancing of the 835. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMT B6 0 Max use 9 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount B6 Allowed - Actual Allowed amount is the amount the payer deems payable prior to considering patient responsibility. AMT-02 782 Service Supplemental Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 98 124 QTY 1200 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop QTY Service Supplemental Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Required when new Federal Medicare or Medicaid mandates require Quantity counts and value of specific quantities identified in the QTY01 qualifier are non-zero. If not required by this implementation guide, do not send. Example QTY ZK 000 Max use 6 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Service Supplemental Quantity Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 99 124 2110 Service Payment Information Loop end 2100 Claim Payment Information Loop end 2000 Header Number Loop end Detail end LQ 1300 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop LQ Health Care Remark Codes To identify standard industry codes Usage notes Use this segment to provide informational remarks only. This segment has no impact on the actual payment. Changes in claim payment amounts are provided in the CAS segments. Required when remark codes or NCPDP Reject Payment codes are necessary for the provider to fully understand the adjudication message for a given service line. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example LQ RX X Max use 99 Optional LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list HE Claim Payment Remark Codes RX National Council for Prescription Drug Programs Reject Payment Codes LQ-02 1271 Remark Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 100 124 Summary PLB 0100 Summary PLB Provider Adjustment To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service Usage notes These adjustments can either decrease the payment (a positive number) or increase the payment (a negative number). Zero dollar adjustments are not allowed. Some examples of PLB adjustments are a Periodic Interim Payment (loans and loan repayment) or a capitation payment. Multiple adjustments can be placed in one PLB segment, grouped by the provider identified in PLB01 and the period identified in PLB02. Although the PLB reference numbers are not standardized, refer to 1.10.2.9 (Interest and Prompt Payment Discounts), 1.10.2.10 (Capitation and | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_24 |
Payment (loans and loan repayment) or a capitation payment. Multiple adjustments can be placed in one PLB segment, grouped by the provider identified in PLB01 and the period identified in PLB02. Although the PLB reference numbers are not standardized, refer to 1.10.2.9 (Interest and Prompt Payment Discounts), 1.10.2.10 (Capitation and Related Payments or Adjustments), 1.10.2.12 (Balance Forward Processing), 1.10.2.16 (Post Payment Recovery) and 1.10.2.17 (Claim Overpayment Recovery) for code suggestions and usage guidelines. The codes and notations under PLB03 and its components apply equally to PLB05, 07, 09, 11 and 13. Required when reporting adjustments to the actual payment that are NOT specific to a particular claim or service. If not required by this implementation guide, do not send. Example PLB XXXX 20250130 HM XXX 000000000000 XX XXXXX 00 000000000 XX XXXX 00 XX XXXXXX 000000000 XX XXXX X 00000 XX XXXXXX 0000 If either Adjustment Identifier (PLB-05) or Provider Adjustment Amount (PLB-06) is present, then the other is required If either Adjustment Identifier (PLB-07) or Provider Adjustment Amount (PLB-08) is present, then the other is required If either Adjustment Identifier (PLB-09) or Provider Adjustment Amount (PLB-10) is present, then the other is required If either Adjustment Identifier (PLB-11) or Provider Adjustment Amount (PLB-12) is present, then the other is required If either Adjustment Identifier (PLB-13) or Provider Adjustment Amount (PLB-14) is present, then the other is required Max use 1 Optional PLB-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB01 is the provider number assigned by the payer. Usage notes When the National Provider Identifier (NPI) is mandated and the provider is a covered health care provider under that mandate, this must be the NPI assigned to the provider. Until the NPI is mandated, this is the provider identifier as assigned by the payer. PLB-02 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 101 124 year PLB02 is the last day of the provider's fiscal year. Usage notes This is the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known by the payer, use December 31st of the current year. PLB-03 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB03 is the adjustment information as defined by the payer. Max use 1 Required C042-01 426 Adjustment Reason Code Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment 50 Late Charge This is the Late Claim Filing Penalty or Medicare Late Cost Report Penalty. 51 Interest Penalty Charge This is the interest assessment for late filing. 72 Authorized Return This is the provider refund adjustment. This adjustment acknowledges a refund received from a provider for previous overpayment. PLB03-2 must always contain an identifying reference number when the value is used. PLB04 must contain a negative value. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. 90 Early Payment Allowance AH Origination Fee This is the claim transmission fee. This is used for transmission fees that are not specific to or dependent upon individual claims. AM Applied to Borrower's Account See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. Use this code to identify the loan repayment amount. This is capitation specific. AP Acceleration of Benefits This is the accelerated payment amount or withholding. Withholding or payment identification is indicated by the sign of the amount in PLB04. A positive value represents a withholding. A negative value represents a payment. B2 Rebate This adjustment code applies when a provider has remitted an overpayment to a health plan in excess of the amount requested by the health plan. The amount accepted by the health plan is reported using code 72 (Authorized Return) and offset by the amount with code WO (Overpayment Recovery). The excess returned by the provider is reported as a negative amount using code B2, returning the excess funds to the provider. B3 Recovery Allowance This represents the check received from the provider for overpayments generated by payments from other payers. This code differs from the provider refund adjustment identified with code 72. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. BD Bad Debt Adjustment This is the bad debt passthrough. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 102 124 BN Bonus This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. C5 Temporary Allowance This is the tentative adjustment. CR Capitation Interest This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. CS Adjustment Provide supporting identification information in PLB03-2. CT Capitation Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. CV Capital Passthru CW Certified Registered Nurse Anesthetist Passthru DM Direct Medical Education Passthru E3 Withholding See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. FB Forwarding Balance This is the balance forward. A negative value in PLB04 represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice. A reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information. FC Fund Allocation This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. The specific fund must be identified in PLB03-2. GO Graduate Medical Education Passthru HM | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_25 |
reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information. FC Fund Allocation This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. The specific fund must be identified in PLB03-2. GO Graduate Medical Education Passthru HM Hemophilia Clotting Factor Supplement IP Incentive Premium Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. IR Internal Revenue Service Withholding IS Interim Settlement This is the interim rate lump sum adjustment. J1 Nonreimbursable This offsets the claim or service level data that reflects what could be paid if not for demonstration program or other limitation that prevents issuance of payment. L3 Penalty This is the capitation-related penalty. Withholding or release is identified by the sign in PLB04. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. L6 Interest Owed This is the interest paid on claims in this 835. Support the amounts related to this adjustment by 2-062 AMT amounts, where AMT01 is "I". LE Levy IRS Levy LS Lump Sum This is the disproportionate share adjustment, indirect medical education passthrough, non-physician passthrough, passthrough lump sum adjustment, or other passthrough amount. The specific type of lump sum adjustment must be identified in PLB03-2. OA Organ Acquisition Passthru OB Offset for Affiliated Providers 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 103 124 Identification of the affiliated providers must be made on PLB03-2. PI Periodic Interim Payment This is the periodic interim lump sum payments and reductions (PIP). The payments are made to a provider at the beginning of some period in advance of claims. These payments are advances on the expected claims for the period. The reductions are the recovery of actual claims payments during the period. For instance, when a provider has a PIP payment, claims within this remittance advice covered by that payment would be offset using this code to remove the claim payment from the current check. The sign of the amount in PLB04 determines whether this is a payment (negative) or reduction (positive). This payment and recoupment is effectively a loan to the provider and loan repayment. See section 1.10.2.5, Advance Payments and Reconciliation, for additional information. PL Payment Final This is the final settlement. RA Retro-activity Adjustment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. RE Return on Equity SL Student Loan Repayment TL Third Party Liability This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. WO Overpayment Recovery This is the recovery of previous overpayment. An identifying number must be provided in PLB03-2. See the notes on codes 72 and B3 for additional information about balancing against a provider refund. WU Unspecified Recovery Medicare is currently using this code to represent penalty collections withheld for the IRS (an outside source). C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Use when necessary to assist the receiver in identifying, tracking or reconcilling the adjustment. See sections 1.10.2.10 (Capitation and Related Payments), 1.10.2.5 (Advanced Payments and Reconciliation) and 1.10.2.12 (Balance Forward Processing) for further information. PLB-04 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount PLB04 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. PLB-05 C042 Adjustment Identifier Max use 1 Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 104 124 To provide the category and identifying reference information for an adjustment - PLB05 is the adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-06 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB06 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-07 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB07 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-08 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB08 is the adjustment amount. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 105 124 Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-09 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB09 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_26 |
reason. PLB-09 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB09 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-10 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB10 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-11 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB11 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 106 124 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-12 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB12 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-13 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB13 is adjustment information as defined by the payer. Usage notes Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-14 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB14 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 107 124 Summary end SE 0200 Summary SE Transaction Set Trailer To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments) Example SE 0000 0001 Max use 1 Required SE-01 96 Transaction Segment Count Min 1 Max 10 Numeric (N0) Required Total number of segments included in a transaction set including ST and SE segments SE-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Numbers in ST02 and SE02 must be identical. The originator assigns the Transaction Set Control Number, which must be unique within a functional group (GS-GE). This unique number also aids in error resolution research. 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 108 124 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE 000000 0000000 Max use 1 Required GE-01 97 Number of Transaction Sets Included Min 1 Max 6 Numeric (N0) Required Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element GE-02 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 109 124 IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA 00000 000000000 Max use 1 Required IEA-01 I16 Number of Included Functional Groups Min 1 Max 5 Numeric (N0) Required A count of the number of functional groups included in an interchange IEA-02 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 110 124 EDI Samples Example 1: Dollars and Data Sent Separately ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 112233 BPR I 1100 C ACH CCP 01 888999777 DA 24681012 1391572880 01 111333555 DA 144444 20190316 TRN 1 71700666555 1391572880 DTM 405 20190314 N1 PR ADVOCARE N3 10 SOUTH AVENUET N4 RAPID CITY SD 55111 PER BL JOHN WAYNE TE 8005551212 EX 123 N1 PE ACME MEDICAL CENTER XX 5544667733 REF TJ 777667755 LX 1 CLP 5554555444 1 800 500 300 12 94060555410000 11 1 NM1 QC 1 BUDD WILLIAM MI 33344555510 AMT AU 800 SVC HC 99211 800 500 DTM 472 20190301 CAS PR 1 300 AMT B6 800 CLP 8765432112 1 1200 600 600 12 9407779923000 11 1 NM1 QC 1 SETTLE SUSAN MI 44455666610 AMT AU 1200 SVC HC 93555 1200 600 DTM | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_27 |
QC 1 BUDD WILLIAM MI 33344555510 AMT AU 800 SVC HC 99211 800 500 DTM 472 20190301 CAS PR 1 300 AMT B6 800 CLP 8765432112 1 1200 600 600 12 9407779923000 11 1 NM1 QC 1 SETTLE SUSAN MI 44455666610 AMT AU 1200 SVC HC 93555 1200 600 DTM 472 20190310 CAS PR 1 600 AMT B6 1200 SE 26 112233 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 111 124 Example 2: Multiple Claims Single Check ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 35681 BPR I 810.8 C CHK 20190331 TRN 1 12345 1391572880 REF EV XYZ CLEARINGHOUSE N1 PR ADVOCARE N3 225 MAIN STREET N4 CENTERVILLE PA 17111 PER BL JANE DOE TE 9005555555 N1 PE BAN DDS LLC XX 9999947036 REF TJ 212121212 LX 1 CLP 7722337 1 226 132 12 119932404007801 11 1 NM1 QC 1 DOE SANDY MI SJD11112 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190324 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 119 74 12 119932404007801 11 1 NM1 QC 1 DOE SALLY MI SJD11111 NM1 IL 1 DOE JOHN MI SJD11111 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 74 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 226 108 24 12 119932404007801 11 1 NM1 QC 1 SMITH SALLY MI SJD11113 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 112 124 AMT B6 25 SVC AD D0220 25 0 DTM 472 20190324 CAS PR 3 14 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 0 DTM 472 20190324 CAS PR 3 10 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 1145 14 902 12 119932404007801 11 1 NM1 QC 1 SMITH SAM MI SJD11116 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 14 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 45 11 AMT B6 14 SVC AD D2790 940 0 DTM 472 20190324 CAS PR 3 756 CAS CO 45 184 SVC AD D2950 180 0 DTM 472 20190324 CAS PR 3 146 CAS CO 45 34 CLP 7722337 1 348 16.8 44.2 12 119932404007801 11 1 NM1 QC 1 JONES SAM MI SJD11122 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 28 SVC AD D4342 125 0 DTM 472 20190313 CAS CO 45 125 SVC AD D4381 43 0 DTM 472 20190313 CAS PR 3 33 CAS CO 45 10 SVC AD D2950 180 16.8 DTM 472 20190313 CAS PR 3 11.2 CAS CO 45 152 AMT B6 28 CLP 7722337 1 226 132 12 119932404007801 11 1 NM1 QC 1 JONES SALLY MI SJD11133 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190321 CAS CO 45 21 AMT B6 25 SVC AD D0220 25 14 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 113 124 DTM 472 20190321 CAS CO 45 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190321 CAS CO 45 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190321 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190321 CAS CO 45 24 AMT B6 49 CLP 7722337 1 179 108 12 119932404007801 11 1 NM1 QC 1 DOE SAM MI SJD99999 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 108 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 129 82 12 119932404007801 11 1 NM1 QC 1 DOE SUE MI SJD88888 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 82 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D1120 54 37 DTM 472 20190324 CAS CO 45 17 AMT B6 37 SVC AD D1208 29 20 DTM 472 20190324 CAS CO 45 9 AMT B6 20 CLP 7722337 1 221 144 12 119932404007801 11 1 NM1 QC 1 DOE DONNA MI SJD77777 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 144 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0330 92 62 DTM 472 20190324 CAS CO 45 30 AMT B6 62 SVC AD D1120 54 37 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 114 124 DTM 472 20190324 CAS CO 45 17 AMT B6 37 SVC AD D1208 29 20 DTM 472 20190324 CAS CO 45 9 AMT B6 20 SE 183 35681 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Security Health 835 Health Care | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_28 |
view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 114 124 DTM 472 20190324 CAS CO 45 17 AMT B6 37 SVC AD D1208 29 20 DTM 472 20190324 CAS CO 45 9 AMT B6 20 SE 183 35681 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 115 124 Example 3: Claim Specific Negotiated Discount ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 35681 BPR I 132 C CHK 20190331 TRN 1 12345 1391572880 REF EV CLEARINGHOUSE N1 PR ADVOCARE N3 225 MAIN STREET N4 CENTERVILLE PA 17111 PER BL JANE DOE TE 9005555555 N1 PE BAN DDS LLC FI 999994703 LX 1 CLP 7722337 1 226 132 12 119932404007801 NM1 QC 1 DOE SALLY MI SJD11111 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 132 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 131 21 AMT B6 25 SVC AD D0220 25 14 DTM 472 20190324 CAS CO 131 11 AMT B6 14 SVC AD D0230 22 10 DTM 472 20190324 CAS CO 131 12 AMT B6 10 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 131 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 131 24 AMT B6 49 SE 35 35681 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 116 124 Example 4: Claim Adjustment Reason Code 45 ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 80.00 C CHK 20190816 TRN 1 CK NUMBER 1 1391572880 REF EV FAC DTM 405 20190827 N1 PR ADVOCARE N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8005481224 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PATACCT 1 400 80 MC CLAIMNUMBER 11 1 NM1 QC 1 DOE JOHN N MI ABC123456789 REF 1L 12345F DTM 050 20190209 PER CX G CUSTOMER SERVICE DEPARTMENT TE 8004074627 AMT AU 150 SVC HC 99213 150 80 1 DTM 472 20190101 CAS CO 45 70 AMT B6 80 SVC HC 85003 100 0 1 DTM 472 20190101 CAS CO 204 100 SVC HC 36415 150 0 1 DTM 472 20190101 CAS CO 97 150 SE 33 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 117 124 Example 5a: Line Service Tax impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 11.06 C CHK 20190816 TRN 1 CK NUMBER 1 1391572880 REF EV FAC DTM 405 20190827 N1 PR ADVOCARE N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8005481224 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PCN 1 36.20 11.06 12 CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 MOA N25 REF 1L 102345 DTM 050 20170113 AMT AU 36.20 SVC HC 99214 26.2 3.06 DTM 472 20170109 CAS CO 45 23.2 137 -.06 REF 6R B1 AMT B6 3 SVC HC 36415 10 8 DTM 472 20170109 CAS CO 45 2 REF 6R B2 AMT B6 8 SE 34 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 118 124 Example 5b: Line Service Bonuses impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 12.00 C CHK 20190816 TRN 1 CK NUMBER 1 1391572880 REF EV FAC DTM 405 20190827 N1 PR ADVOCARE N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8005481224 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PCN 1 25 12 10 12 CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 MOA N25 REF 1L 102345 DTM 050 20170113 AMT AU 25 SVC HC 99214 25 12 DTM 472 20170109 CAS CO 45 5 161 -2 CAS PR 3 10 REF 6R 123 AMT B6 20 SE 30 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 119 124 Example 5c: Line Service Penalty impacting payment only ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 8.00 C CHK 20190816 TRN 1 CK NUMBER 1 1391572880 REF EV FAC DTM 405 20190827 N1 PR ADVOCARE N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8005481224 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PCN 1 25 8 10 12 CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 MOA N25 REF 1L 102345 DTM 050 20170113 AMT AU 25 SVC HC 99214 25 8 DTM 472 20170109 CAS | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_29 |
CA 12211 REF TJ 123456789 LX 1 CLP PCN 1 25 8 10 12 CLAIMNUMB 11 1 NM1 QC 1 LAST FIRST J MI 123456789 NM1 82 1 XX 1447481825 MOA N25 REF 1L 102345 DTM 050 20170113 AMT AU 25 SVC HC 99214 25 8 DTM 472 20170109 CAS CO 45 5 B4 2 CAS PR 3 10 REF 6R 123 AMT B6 20 SE 30 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 120 124 Example 6: Not Covered Not Authorized Inpatient Facility claim days ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 8000.00 C CHK 20190816 TRN 1 CK NUMBER 1 1391572880 REF EV FAC DTM 405 20190827 N1 PR ADVOCARE N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8005481224 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PATACCT 1 40000 8000 MC CLAIMNUMBER 11 1 CAS CO 197 2000 1 45 30000 NM1 QC 1 DOE JOHN N MI ABC123456789 REF 1L 12345F DTM 232 20190101 DTM 233 20190105 DTM 050 20190209 PER CX G CUSTOMER SERVICE DEPARTMENT TE 8004001212 AMT AU 38000 QTY CA 4 SE 27 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 121 124 Example 8a: Claim submitted with incorrect subscriber as patient and incorrect ID ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 120.03 C CHK 20190816 TRN 1 CK NUMBER 1 1391572880 REF EV FAC DTM 405 20190827 N1 PR ADVOCARE N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8005481224 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP 04777796TLC777122 1 155 120.03 13 8838888212 11 1 NM1 QC 1 MASTERS MARVIN L MI 80444444403 NM1 IL 1 CABLE MABEL MI 80444444403 NM1 74 1 MASTERS MARVIN C 80444444401 NM1 82 1 SHELTON MD BLAKE XX 1666666666 REF 1L 28 DTM 232 20191114 DTM 233 20181114 DTM 050 20181119 AMT AU 155 SVC HC 99393 155 120.03 1 DTM 472 20181114 CAS CO 45 34.97 REF 6R 22261822 AMT B6 120.03 SE 32 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 122 124 Example 8b: Claim submitted with incorrect subscriber name and ID ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 35.06 C CHK 20190816 TRN 1 CK NUMBER 1 1391572880 REF EV FAC DTM 405 20190827 N1 PR ADVOCARE N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8005481224 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP 02333TLC222222 1 115 35.06 35 13 8333333214 11 1 NM1 QC 1 KEATON ALEX P MI 80000006006 NM1 IL 1 THOMAS JASON MI 80000006006 NM1 74 1 JEROME C 80000006001 NM1 82 1 BLOOD MD RED N XX 1888888886 REF 1L 28 DTM 232 20191113 DTM 233 20191113 DTM 050 20191119 AMT AU 115 SVC HC 99213 115 35.06 1 DTM 472 20191113 CAS CO 45 44.94 CAS PR 3 35 REF 6R 22261389 AMT B6 70.06 SE 33 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 123 124 Stedi is a registered trademark of Stedi, Inc. 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Example 8c: Claim submitted with for subscriber missing the Middle initial ISA 00 00 ZZ ABCPAYER ZZ ABCPAYER 190827 0212 00501 191511902 0 P GS HP ABCD ABCD 20190827 12345678 12345678 X 005010X221A1 ST 835 10060875 BPR I 2415.25 C CHK 20190816 TRN 1 CK NUMBER 1 1391572880 REF EV FAC DTM 405 20190827 N1 PR ADVOCARE N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8005481224 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP 05444444TLC999999 1 3903 2415.25 13 8777777782 21 1 NM1 QC 1 GONZALES SAMMY MI 80455555502 NM1 IL 1 LAPLANTE FERN MI 80455555502 NM1 74 1 R NM1 82 1 GOOD MD ROBERT B XX 19999999987 REF 1L 28 DTM 232 20191101 DTM 233 20191101 DTM 050 20191114 AMT AU 3903 SVC HC 59400 3903 2415.25 1 DTM 472 20191101 CAS CO 45 1487.75 REF 6R 22215592 AMT B6 2415.25 SE 32 10060875 GE 1 12345678 IEA 1 191511902 1 29 25, 8:52 PM Security Health 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-paymentadvice-x221a1 01H25KKVA6Q3PW0CJ2PES5TEHE 124 124 | /kaggle/input/edi-db/Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 180e8b2afd45878a1de976c4300ef6ab | 180e8b2afd45878a1de976c4300ef6ab_30 |
837 Health Care Claim Companion Guide Professional and Institutional Revised December 2011 Table of Contents Introduction........................................................................................................... 3 Purpose................................................................................................................ 3 References........................................................................................................... 3 Additional information........................................................................................... 4 Delimiters Supported......................................................................................... 4 Maximum Limitations......................................................................................... 4 Submission Specifications................................................................................. 4 Interchange Control Header Specification............................................................ 6 Interchange Control Trailer Specification.............................................................. 6 Functional Group Header Specification................................................................ 7 Functional Group Trailer Specification.................................................................. 7 837 Professional Claim Transaction Specifications.............................................. 8 837 Institutional Claim Transaction Specifications.............................................. 10 2 Introduction The Health Insurance Portability and Accountability Act (HIPAA) of 1996 was passed in order to provide better access to health insurance, limit fraud and abuse, and reduce administrative costs of the health care industry. This act required the Department of Health and Human Services (HHS) to adopt standards that support the electronic data interchange (EDI) of health care transactions. In order for the industry to achieve its desired goal, all organizations involved in electronic interchange of data must comply with the standard transactions and code sets that have been developed. These guidelines are outlined in the ANSI X12N 837 Health Care Claims transaction implementation guides. By adopting these standards the efficiency and effectiveness of the health care will improve by encouraging the use of electronic data interchange throughout the industry. This latest version of the Companion Guide contains the changes necessary to ensure compliance with 45 CFR Part 162, CMS-009-F. Purpose The purpose of this document is to provide submitters with the necessary information to successfully submit electronic claims to Advanced Behavioral Health, Inc (ABH). This companion guide should be used in combination with the ANSI X12N 837 implementation guides. These guides are available from Washington Publishing Company on their website at www.wpc- edi.com hipaa. Types of transactions accepted by ABH are: 837 Professional Health Care Claim ASC X12 837 837 Institutional Health Care Claim ASC X12 837 For those submitters who have previously submitted State of CT General Assistance batch claims electronically, no changes have been made other than the names of the parties involved. For those submitters who have not submitted electronic claims in the past, this companion guide will describe specific requirements necessary for processing claims through Advanced Behavioral Health s system. This guide in no way replaces any requirements that are found in the ANSI X12N implementation guides. References Listed below are some additional websites containing information that may be helpful during the implementation process: Accredited Standards Committee (ASC X12N) http: www.x12n.org Centers for Medicare and Medicaid Services (CMS) http: www.cms.hhs.gov hipaa United States Department of Health and Human Services (DHHS) http: aspe.hhs.gov admnsimp Washington Publishing Company http: wpc-edi.com hipaa 3 Additional information Delimiters Supported A delimiter is a character that is used to separate data elements, or mark the end of a segment. The preferred delimiters for electronic data are an ( ) asterisk for separation of data elements, a (:) colon for separation of sub-elements, and ( ) tilde for indication of a segment end. Other delimiters will be accepted according to the ANSI X12N guidelines. Note that once a delimiter has been specified, it cannot be used in the data elements transferred or it will cause the file to be rejected. Maximum Limitations The 837 transaction is designed to submit one or more claims per billing provider. The hierarchy built into the structure is billing provider, subscriber, patient, claim, and claim service. The number of times that each of these loops may repeat is defined in the implementation guides. For example, there cannot be more than 100 claims per client, and no more than 50 service lines per professional claim 999 service lines per institutional claim. ABH will require that only one interchange be submitted per transaction. In addition, there may be only one type of claim (institutional or professional) submitted per interchange, and therefore per file. When files are validated, after being submitted to ABH, they will be checked and accepted (pass) or rejected (fail) based on the entire file s formatting. Therefore, partial files will not be accepted. Providers will be notified of this response via a download page on the ABH website. If a file is rejected, the message will indicate to the provider what they will need to correct. If there are questions about any error messages that are unclear, please contact the ABH customer service for assistance. Submission Specifications Provider organizations who wish to submit electronic 837 transactions to Advanced Behavioral Health must have a valid submitter id and password. If you do not have this information you may acquire one by contacting the Customer Support at 800-606-3677 X6440 or downloading, completing and submitting the form on ABH s website at http: www.abhct.com resources_gabhp.asp. In addition, provider organizations wishing to submit batch claims electronically to ABH must submit one accepted, error free test file and receive verification that the file loaded successfully before submitting production files. In order to submit test files, an ID and password will be assigned by filling out the access form referenced above. The ID will allow submitters to submit only test files until the successful file has been received, at which time the ID will be activated for production files. Provider organizations who will be submitting their claims through the single data-entry claims system on the Internet will not need to test any files and will be able to start submitting claims as soon as they receive their ID and password. 4 If your provider organization utilizes a third-party health care clearinghouse or other agency to submit batch claim files, the organization must submit a copy of a signed Business Associate or Trading Partner agreement along with the access request form. The Department of Mental Health Addiction Services reserves the right to make final decisions regarding approval of access for third-party agencies. If you have further questions about obtaining access for a third- party agency, please contact our Provider Relations Department at (800) 606-3677, Ext. 6440. 5 Interchange Control Header Trailer Specifications Seg Data Element Name Usage Comments Expected Value ISA Interchange Control Header R ISA01 Authorization Information Qualifier R Use '03' Additional Data Identification to indicate that a login ID is present in ISA02. ISA02 Authorization Information R Information used for additional identification or authorization. Use the ABH Submitter | /kaggle/input/edi-db/837 Health Care Claim Companion Guide Rev 12 2011.pdf | 85a8528b1eeb2fb3eeb424b143cdb49f | 85a8528b1eeb2fb3eeb424b143cdb49f_0 |
Trailer Specifications Seg Data Element Name Usage Comments Expected Value ISA Interchange Control Header R ISA01 Authorization Information Qualifier R Use '03' Additional Data Identification to indicate that a login ID is present in ISA02. ISA02 Authorization Information R Information used for additional identification or authorization. Use the ABH Submitter ID as the login ID. ISA03 Security Information Qualifier R Use '01 Password to indicate that a password is present in ISA04. ISA04 Security Information R Additional security information identifying the sender. Use the ABH Submitter ID password. ISA05 Interchange ID Qualifier R Refer to the implementation guide for a list of valid qualifiers. ISA06 Interchange Sender ID R Refer to the implementation guide specifications. ISA07 Interchange ID Qualifier R Use 'ZZ' Mutually Defined ISA08 Interchange Receiver ID R Use 'ABH ' ISA09 Interchange Date R Date format YYMMDD ISA10 Interchange Time R Time format HHMM ISA11 Interchange Repitition Separator R ISA12 Interchange Control Version Number R Valid values: '00501' Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003 Use the current standard approved for the ISA IEA envelope. ISA13 Interchange Control Number R The interchange control number must match the interchange trailer IEA02. This value is to be defined by the senders system. If not used, this field must be zero filled. ISA14 Acknowledgement Requested R Valid values: '0' No Acknowledgement Requested '1' Interchange Acknowledgement Requested ISA15 Usage Indicator R Valid values: 'P' Production 'T' Test This Usage Indicator should be set appropriately. When submitting initial tests use 'T', for all other files use 'P'. ISA16 Component Element Separator R The delimiter must be a unique character not found in any of the data included in the batch. This element will contain the delimiter that will be used to separate components within a data element. This value must be different from the element separator and segment terminator. Seg Data Element Name Usage Comments Expected Value IEA Interchange Control Trailer R IEA01 Number of Included Functional Groups R Count of the number of functional groups in the interchange. IEA02 Interchange Control Number R The interchange control number in IEA02 must match the interchange header value sent in ISA13. The interchange control numbers in the IEA and ISA segments will be compared. If the numbers do not match the file will be rejected. Header Trailer 6 Functional Group Header Trailer Specifications Seg Data Element Name Usage Comments Expected Value GS Functional Group Header R GS01 Functional Identifier Code R Valid values: 'HC' Health Care Claims (837) Use 'HC' Health Care Claims (837) GS02 Application Sender's Code R The sender defines this value. GS03 Application Receiver's Code R This field identifies how the file was received by ABH. Use 'EDI' for electronic transfer of data. GS04 Date R Date format CCYYMMDD GS05 Time R Time format HHMM. GS06 Group Control Number R The group control number in GS06 must be the same as the associated group trailer element (GE02). GS07 Responsible Agency Code R Valid values: 'X' Accredited Standards Committee X12 Use 'X' Accredited Standards Committee X12 GS08 Version Release Industry ID Code R Valid values: '005010X222A1' - Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003. '005010X223A2' - Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003. Use the current standard approved for publication by ASC X12. Seg Data Element Name Usage Comments Expected Value GE Functional Group Trailer R GE01 Number of Transaction Sets IncludedR Count of the number of transaction sets in the functional group. Only similar transaction sets may be included in the functional group. GE02 Group Control Number R The group control number in GE02 must match that sent in the group header (GS06). The group control numbers in the GE and GS segments will be compared. If the numbers do not match the file will be rejected. Header Trailer 7 837 Professional Claim Transaction Specifications Seg Data Element Name Usage Comments Expected Value BHT Beginning of Hierarchical Transaction R BHT02 Transaction Set Purpose Code R Valid values: '00' Original '18' Reissue Case Use '00' Original. BHT06 Transaction Type Code R Use 'CH' for claims NM1 Submitter Name R NM109 Submitter Primary Identifier R This element contains the ETIN (Electronic Transaction Identifier Number). Use the ABH Submitter ID. NM1 Receiver Name R NM103 Receiver Name R Use 'Advanced Behavioral Health, Inc.' NM109 Receiver Primary Identifier R This element contains the ETIN (Electronic Transaction Identifier Number). Use 'ABH'. PRV Billing Pay-To Provider Specialty Information R PRV02 Provider Specialty Code Qualifier R Use 'PXC' PRV03 Provider Taxonomy Code R Send the providers taxonomy code. NM1 Billing Provider Name R NM108 Billing Provider Identification Code Qualifier R Use 'XX' NM109 Billing Provider Identifier R Send the Provider's National Provider ID (NPI) N4 Billing Provider City State Zip Code R N403 Billing Provider Zip Code R Send the Provider's 9-digit zip code. REF Billing Provider Secondary Identification S When NPI is submitted in NM108 109, the provider must send either their EIN or SSN in the REF loop. REF01 Reference Identification Qualifier R Use: 'EI' Tax ID (to indicate the provider's EIN) 'SY' SSN (to indicate the provider's SSN) REF02 Billing Provider Additional Identifier R Send the Provider's EIN SSN NM1 Subscriber Name R NM108 Identification Code Qualifier S Required if the subscriber is a person (NM102 1). Also required if the subscriber is the patient. Use 'MI' Member Identification Number. NM109 Subscriber Primary Identifier S Use the client's EMS ID. NM1 Payer Name R NM103 Payer Name R Destination Payer Name Use 'Advanced Behavioral Health, Inc.' NM108 Identification Code Qualifier R Use 'PI' Payer Identifier NM109 Payer Identifier R Destination Payer Identifier Use 'ABH'. CLM Claim Information R CLM01 Claims Submitter's Identifier R Patient's Account Number entered here will be returned on the EOB. NM1 Referring Provider Name S NM108 Identification Code Qualifier S Use 'XX'. NM109 Identification Code S Use the National Provider ID (NPI) of the referring provider. REF Referring Provider Secondary Identification S REF01 Reference Identification Qualifier R Required if a secondary number is necessary to identify the provider. The primary identifier should be sent in NM108 109 in | /kaggle/input/edi-db/837 Health Care Claim Companion Guide Rev 12 2011.pdf | 85a8528b1eeb2fb3eeb424b143cdb49f | 85a8528b1eeb2fb3eeb424b143cdb49f_1 |
Qualifier S Use 'XX'. NM109 Identification Code S Use the National Provider ID (NPI) of the referring provider. REF Referring Provider Secondary Identification S REF01 Reference Identification Qualifier R Required if a secondary number is necessary to identify the provider. The primary identifier should be sent in NM108 109 in this loop. Use 'G2' REF02 Referring Provider Secondary Identification R Header Loop 1000A - Submitter Name Loop 1000B - Receiver Name Loop 2010AA - Billing Provider Name Loop 2000A - Billing Pay-To Provider Specialty Information Loop 2010BA - Subscriber Name Loop 2010BB - Payer Name Loop 2300 - Claim Information Loop 2310A - Referring Provider Name 8 837 Professional Claim Transaction Specifications Seg Data Element Name Usage Comments Expected Value NM1 Rendering Provider Secondary Identification S NM108 Identification Qualifier R Use 'XX'. NM109 Rendering Provider Identification R Use the National Provider ID (NPI) of the rendering provider. SV1 Professional Service R SV101 Composite Medical Procedure Identifier R SV101-1 Product Service ID Qualifier R Use 'HC' Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes. SV101-3 SV101-4 SV101-5 SV101-6 Procedure Modifier S SV104 Quantity S Use whole number unit values. DTP Date - Service Date R DTP02 Date Time Period Qualifier R Valid values: 'D8' Single Date (CCYYMMDD) 'RD8' Range of Dates Use 'RD8' to specify a range of dates. The from and thru service dates should be sent for each service line. Loop 2400 - Service Line Loop 2310B - Rendering Provider Name 9 837 Institutional Claim Transaction Specifications Seg Data Element Name Usage Comments Expected Value BHT Beginning of Hierarchical Transaction R BHT02 Transaction Set Purpose Code R Valid values: '00' Original '18' Reissue Case Use '00' Original. BHT06 Transaction Type Code R Use 'CH' for claims NM1 Submitter Name R NM109 Submitter Primary Identifier R This element contains the ETIN (Electronic Transaction Identifier Number). Use the ABH Submitter ID. NM1 Receiver Name R NM103 Receiver Name R Use 'Advanced Behavioral Health, Inc.' NM109 Receiver Primary Identifier R This element contains the ETIN (Electronic Transaction Identifier Number). Use 'ABH'. PRV Billing Pay-To Provider Specialty Information R PRV02 Provider Specialty Code Qualifier R Use 'PXC' PRV03 Provider Taxonomy Code R Send the providers taxonomy code. NM1 Billing Provider Name R NM108 Billing Provider Identification Code Qualifier R Use 'XX' NM109 Billing Provider Identifier R Send the Provider's National Provider ID (NPI) N4 Billing Provider City State Zip Code R N403 Billing Provider Zip Code R Send the Provider's 9-digit zip code. REF Billing Provider Secondary Identification S When NPI is submitted in NM108 109, the provider must send their EIN in the REF loop. REF01 Reference Identification Qualifier R Use: 'EI' Tax ID (to indicate the provider's EIN) REF02 Billing Provider Additional Identifier R Send the Provider's EIN NM1 Subscriber Name R NM108 Identification Code Qualifier S Required if the subscriber is a person (NM102 1). Also required if the subscriber is the patient. Use 'MI' Member Identification Number. NM109 Subscriber Primary Identifier S Use the client's EMS ID. NM1 Payer Name R NM103 Payer Name R Destination Payer Name Use 'Advanced Behavioral Health, Inc.' NM108 Identification Code Qualifier R Use 'PI' Payer Identifier NM109 Payer Identifier R Destination Payer Identifier Use 'ABH'. CLM Claim Information R CLM01 Claims Submitter's Identifier R Patient's Account Number entered here will be returned on the EOB. CLM05 Health Care Service Location Information R CLM05-3 Claim Frequency Type Code R UB-92 Type of Bill. Valid values: '1' - Admit through Discharge Claim '2' - Interim - First Claim '3' - Interim - Continuing Claim '4' - Interim - Last Claim '5' - Late Charge Only Use '1', '2', '3', '4', or '5' REF Original Reference Number (ICN DCN) S REF02 Original Reference Number (ICN DCN) R When submitting an Original Reference Number use the number with the prefix of 'RC'. HI Principal Procedure Information S HI01 Health Care Code Information R HI01-1 Code List Qualifier R Use 'BR' Health Care Financing Administration Common Procedural Coding System Principal Procedure. HI Other Procedure Information S HI01 Health Care Code Information R HI01-1 Code List Qualifier R Use 'BQ' Health Care Financing Administration Common Procedural Coding System. Loop 2010BA - Subscriber Name Loop 2010BB - Payer Name Header Loop 1000A - Submitter Name Loop 1000B - Receiver Name Loop 2010AA - Billing Provider Name Loop 2000A - Billing Pay-To Provider Specialty Information Loop 2300 - Claim Information 10 837 Institutional Claim Transaction Specifications Seg Data Element Name Usage Comments Expected Value SV2 Institutional Service Line R SV202 Composite Medical Procedure Identifier S SV202-1 Product Service ID Qualifier R Use 'HC' Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes. SV202-3 SV202-4 SV202-5 SV202-6 Procedure Modifier S SV205 Quantity S Use whole number unit values. DTP Date - Service Date R DTP02 Date Time Period Qualifier R Valid values: 'D8' Single Date (CCYYMMDD) 'RD8' Range of Dates Use 'RD8' to specify a range of dates. The from and thru service dates should be sent for each service line. Loop 2400 - Service Line Number 11 | /kaggle/input/edi-db/837 Health Care Claim Companion Guide Rev 12 2011.pdf | 85a8528b1eeb2fb3eeb424b143cdb49f | 85a8528b1eeb2fb3eeb424b143cdb49f_2 |
HIPAA Transaction Standard Companion Guide Healthcare Claim Payment Advice ASC X12N 835 Version 005010X221A1 for State of Idaho MMIS Date of Publication: 02 29 2024 Document Number: TL419 Version: 11.0 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page ii Revision History Version Date Author Action Summary of Changes 1.0 07 01 2011 Molina Initial document 1.1 09 09 2013 Molina Modified to conform to CAQH CORE standards 1.2 11 11 2013 Molina Updated with DHW requested changes 1.3 01 14 2014 Molina Changed the Data Flow Diagram in Section 4, and added information about Web Services in Section 4 2.0 01 31 2014 TQD DHW approved 1 27 2014 2.1 04 28 2014 J Phillips Added information about sending acknowledgements via Upload and VAN in Section 4 Connectivity with the Payer Communications Process Flows per CR 35250 3.0 05 14 2014 TQD DHW validated 5 5 2014 3.1 05 20 2015 M McFadden Semi-annual review performed made changes 3.2 05 26 2015 Hope McCain Removed references to retired TPA user guides. 4.0 06 15 2015 TQD DHW validated 6 10 2015 4.0 12 22 2015 D Greer Semi-annual review no changes 4.0 5 26 2016 J Phillips Semi-annual review no changes 4.1 12 19 2016 J Richardson Semi-annual review remove secured FTP information and replace with VAN 5.0 1 18 2017 TQD DHW validated 1 12 2017 5.1 6 7 2017 Douglas Greer Semi-annual review minor corrections 6.0 7 27 2017 TQD DHW validated changes 7 27 17 6.1 8 15 2017 Hope McCain Updated for TPA upgrade 6.2 11 22 2017 Hope McCain Additional updates based on State review 7.0 12 1 2017 TQD DHW validated changes 11 30 17 7.0 6 21 2018 J Richardson Semi-annual review no changes 7.1 10 5 2018 M Zampierin Removed Molina reference and replaced with DXC Technology 7.1 11 27 2018 Jimmy Phillips Semi-annual review no changes 7.1 3 1 2019 Jimmy Phillips Semi-annual review no changes 7.1 3 29 2019 Cathy Lavacchia Semi-annual review no changes 7.1 11 27 2019 Jimmy Phillips Semi-annual review no changes 7.2 03 10 2020 Cathy Lavacchia Changed for Rebranding CR 58031 8.0 03 30 2020 TQD Finalized per DHW validated changes. 8.0 4 22 2021 Douglas Greer Semi-annual review no changes 8.1 11 22 2021 Jen Richardson CMS semi-annual review, no content updates. Rebranding changes only. Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page iii Version Date Author Action Summary of Changes 9.0 01 21 2022 TQD Finalized for publishing after rebranding 9.0 06 03 2022 Jimmy Phillips Reviewed for semi-annual; no updates necessary. 9.1 08 24 2022 Myranda Payne Clarified Register link location in section 2.2 Trading Partner Registration 10.0 09 30 2022 TQD Finalized per DHW validated changes. 10.0 11 23 2022 Jimmy Phillips Reviewed for semi-annual; no updates necessary. 10.1 05 24 2023 Kelsey Nielsen Changed the sentence "FTP though a secure, dedicated VAN connection." to "FTP through a secure, dedicated VAN connection." 10.2 11 16 2023 Kelsey Nielsen Semi-annual review; Grammatical corrections 10.3 01 25 2024 Jimmy Phillips Changed for Gainwell rebranding project CR 76444 11.0 02 29 2024 TQD Finalized per DHW validated changes. 2020-2024 Gainwell Technologies Company. All rights reserved. Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page iv Table of Contents Introduction........................................................................................................ 1 1.1. Scope........................................................................................................... 2 1.2. Overview...................................................................................................... 2 1.3. References.................................................................................................... 2 1.4. Additional Information.................................................................................... 2 Getting Started.................................................................................................... 3 2.1. Working with Gainwell Technologies................................................................ 3 2.2. Trading Partner Registration............................................................................ 3 2.3. Certification and Testing Overview.................................................................... 3 Testing with the Payer.......................................................................................... 3 Connectivity with the Payer Communications Process Flows...................................... 3 4.1. Process Flows................................................................................................ 4 4.2. Transmission Administrative Procedures........................................................... 5 4.3. Re-Transmission Procedure............................................................................. 5 4.4. Communication Protocol Specifications............................................................. 5 4.5. Passwords..................................................................................................... 6 Contact Information............................................................................................. 6 5.1. Gainwell Technologies EDI Helpdesk and EDI Technical Assistance....................... 6 5.2. Provider Service Number................................................................................ 6 5.3. Applicable Websites E-mail.............................................................................. 7 Control Segments and Envelopes.............................................................................. 7 6.1. Delimiters..................................................................................................... 7 6.2. ISA-IEA........................................................................................................ 7 6.3. GS-GE.......................................................................................................... 7 6.4. ST-SE........................................................................................................... 7 Payer-Specific Business Rules and Limitations......................................................... 8 Acknowledgments and or Reports.......................................................................... 8 8.1. Report Inventory (Not Sent for 835 Transactions)............................................. 8 Trading Partner Agreements.................................................................................. 8 Transaction Specific Information......................................................................... 8 Appendices..................................................................................................... 22 Appendix A. Implementation Checklist..................................................................... 22 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 1 of 22 Introduction This section describes how the 5010 X12 Type 3 Technical Reports (TR3) adopted under HIPAA will be detailed using a table. The tables contain a row for each segment where Gainwell Technologies has something additional, over and above the information in the TR3. That information can: Limit the repeat of loops or segments Limit the length of a simple data element Specify a sub-set of the TR3s internal code listings Clarify the use of loops, segments, composite and simple data elements Specify any other information tied directly to a loop, segment, composite, or simple data element pertinent to trading electronically with Gainwell Technologies In addition to the row for each segment, one or more additional rows are used to describe Gainwell Technologies' usage for composite and simple data elements and any other information. Notes and comments should be placed at the deepest level of detail. For example, a note about a code value should be placed on a row specifically for that code value, not in a general note about the segment. The following table specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides. Page Loop ID Referenc e Name Codes Length Notes Comments 193 2100C NM1 Subscriber Name This row type always indicates that a new segment has begun. It is always shaded at 10, and notes or comments about the segment go in this cell. 195 2100C NM109 Subscriber Primary Identifier 15 This row type exists to limit the length of the specified data element. 196 2100C REF Subscriber Additional 197 2100C REF01 Reference Identification Qualifier 18, 49, 6P, These are the only codes transmitted by Gainwell MS Healthcare. Plan Network Identification Number N6 This row type exists when a note | /kaggle/input/edi-db/CAQH 5010 835 Companion Guide.pdf | 69f62a9d267e4454bc0b0364e4df734f | 69f62a9d267e4454bc0b0364e4df734f_0 |
15 This row type exists to limit the length of the specified data element. 196 2100C REF Subscriber Additional 197 2100C REF01 Reference Identification Qualifier 18, 49, 6P, These are the only codes transmitted by Gainwell MS Healthcare. Plan Network Identification Number N6 This row type exists when a note for a particular code value is required. For example, this note may say that value N6 is the default. Not populating the first 3 columns makes it clear that the code value belongs to the row immediately above it. 218 2110C EB Subscriber Eligibility or Benefit 231 2110C EB13-1 Product Service ID Qualifier AD This row illustrates how to indicate a component data element in the Reference column and specify that only one code value is applicable. Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 2 of 22 1.1. Scope This companion guide documents the transaction type listed below and further defines situational and required data elements for processing the 835 healthcare claim payment advice for programs administered by Idaho Medicaid. This document is not the complete EDI transaction format specifications. The complete EDI 835 transaction format can be found in the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Health Care Claim Payment Advice (835), as noted in the References section below. Healthcare Claim Payment Advice ASC X12N 835 (005010X221) Addenda Healthcare Claim Payment Advice ASC X12N 835 (005010X221A1) 1.2. Overview Data elements, segments, and loops not included in this guide are not used for processing transactions by Idaho Medicaid but will still be sent if the information is required for compliance with the ASC X12N version 5010A1 format. See the References section below. 1.3. References Please refer to the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Health Care Claim Payment Advice (835) for information not supplied in this document, such as code lists, definitions, and edits. This TR3 Guide can be obtained from the Washington Publishing Company. Their website is https: www.wpc-edi.com. 1.4. Additional Information The CCD and X12 835 TR3 TRN Segment were adopted together as the Federal Healthcare EFT Standards in CMS-0024-IFC: Administrative Simplification: Adoption of Standards for Health Care Electronic Funds Transfers (EFTs) and Remittance Advice. The 835 Healthcare Claim Payment Advice allows automated matchup of claims payment data sent to the Receiver from Idaho Medicaid using computer software. The delivery and use of the 835 Healthcare Claim Payment continues to increase compliance with HIPAA-adopted administrative transactions and encourages entities to use this infrastructure eligibility and claim status. Adoption of the 835 Healthcare Claim Payment Advice simplifies and standardizes information to match the payment to the remittance advice detail, thereby decreasing confusion around electronic funds transfer (EFT) and ERA. Consistent and uniform rules enable providers to match and process both the EFT payment and the v5010 X12 835 and help mitigate: o Unnecessary manual provider follow-up o Faulty electronic secondary billing o Inappropriate write-offs of billable charges o Incorrect billing of patients for co-pays and deductibles o Posting delays And provide for: o Less staff time spent on phone calls and websites o Increased ability to conduct targeted follow-up with health plans and or patients o More accurate and efficient payment of claims If you do not already receive the 835 Healthcare Claim Payment Advice (electronically), please contact the EDI Help Desk today at 1 (866) 686-4272 and select option 2 when prompted for more information. Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 3 of 22 Getting Started 2.1. Working with Gainwell Technologies Please visit https: www.idmedicaid.com and click on the Companion Guides link under Reference Material to view the latest versions of this and other X12 Companion Guides. For information on how to use the portal once registered as a trading partner, click the User Guides link under Reference Material. For any questions or to begin testing, contact the Gainwell Technologies EDI Helpdesk at 1 (866) 686-4272 option 2, or e-mail us at idedisupport gainwelltechnologies.com. 2.2. Trading Partner Registration A Trading Partner Account (TPA) is any entity with which Gainwell Technologies exchanges electronic data. The term electronic data is not limited to HIPAA X12 transactions. Gainwell Technologies will assign trading partner IDs to support the exchange of X12 EDI transactions for providers, billing agencies and clearinghouses, and other health plans. To become a trading partner and get your trading partner ID, please visit our website at https: www.idmedicaid.com and click the Register link in the upper right-hand corner of the screen. You may also contact us at 1 (866) 686-4272, option 2. 2.3. Certification and Testing Overview All TPA must be authorized to submit production EDI transactions. Authorization is granted on a per-transaction basis. For example, a trading partner may be certified to submit 837P professional claims but not certified to submit 837I institutional claim files. Any TPA may submit test EDI transactions. The Usage Indicator, element 15 of the Interchange Control Header (ISA) of an X12 file, indicates if a file is test or production. Testing with the Payer Trading partners must submit three test files of a particular transaction type, with a minimum of fifteen transactions within each file, and have no failures or rejections to become certified for production. Users will be notified via e-mail and the Trading Partner Status page of the Health PAS website when testing for a particular transaction has been completed. The Trading Partner Status page is found by logging into your trading partner account on the Health PAS website (https: www.idmedicaid.com), hovering over the Account Management tab, and then clicking User Status. Detailed instructions for retrieving and interpreting HIPAA validation acknowledgments may be found on the Health PAS website under Companion Guides in the 5010 Appendix A Vendor Specs document. Connectivity with the Payer Communications Process Flows Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 4 of 22 4.1. Process Flows Below is the TPA Portal Services Process Flow (Retrieval of an 835 using the TPA Portal Services). Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice | /kaggle/input/edi-db/CAQH 5010 835 Companion Guide.pdf | 69f62a9d267e4454bc0b0364e4df734f | 69f62a9d267e4454bc0b0364e4df734f_1 |
Flows Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 4 of 22 4.1. Process Flows Below is the TPA Portal Services Process Flow (Retrieval of an 835 using the TPA Portal Services). Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 5 of 22 Below is the CAQH Web Services Process Flow (Generic Batch Retrieval Request of an 835). 4.2. Transmission Administrative Procedures X12 files (including an acknowledgment of an 835) can be uploaded via the Health PAS website File Exchange X12 Upload. 835 Healthcare Claim Payment Advice transaction files, acknowledgments, and responses to transactions submitted via the Health PAS website can be accessed by selecting Responses under the File Exchange menu. Trading Partners who have established a VAN connection and submitted X12 transactions via the VAN connection may retrieve acknowledgments and responses from their designated VAN Pickup locations. A VAN connection is a secure VPN connection through which X12 files are transferred via the FTP protocol. 4.3. Re-Transmission Procedure ISA13 Interchange Control Number needs to be unique to each file and Trading Partner ID. 4.4. Communication Protocol Specifications The following communications protocols are available for receiving the ASC X12N 835 transaction Files. Batch Mode: HTTPS download via the Health PAS website FTP through a secure, dedicated VAN connection CAQH Web Service: Authorized trading partners can request 835 transactions through CAQH Web Services. Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 6 of 22 CAQH Phase III requires that a 999 be returned to the issuer of the 835 to acknowledge receipt and, if appropriate, report errors encountered with the 835 data1. The Gainwell Technologies CAQH Web Services have been enhanced to support this functionality. The CAQH Web Services support two types of transaction protocols: SOAP (Simple Object Access Protocol) and MIME (Multipurpose Internet Mail Extensions). Transactions can be sent through the following links: SOAP Transactions: https: www.idmedicaid.com CAQH_SOAPService SOAPService.svc MIME Transactions: https: www.idmedicaid.com CAQH_MIMEService MIMEService.svc When requesting an 835 using the CAQH Web Services: The PayloadID needs to be set to the Check EFT Payment ID for the desired 835 The PayloadType needs to be specified as X12_835_Request_005010X221A1 The ProcessingMode needs to be set to Batch The requesting Trading Partner ID must match the Receiver ID of the 835 transaction requested When sending a 999 response using the CAQH Web Services: Set the 999 AK102 to the value of the GS06 value for the 835 that the 999 is in response to The PayloadType should be set to X12_999_SubmissionRequest_005010X231A1 The ProcessingMode needs to be set to Batch The following Operations and Messages are supported: Operation Request Response GenericBatchRetrievalRequest GenericBatchRetrievalRequestMessage GenericBatchRetrievalResp onseMessage PayloadReceiptConfirmation PayloadReceiptConfirmationRequestMes sage PayloadReceiptConfirmatio nResponseMessage 4.5. Passwords Trading Partners create their passwords at the time of registration and are required to update them every 60 days per the Health PAS-Online requirements. The password must be at least seven (7) characters long, contain at least one (1) uppercase character, at least one (1) numeral, and at least one (1) special character (!). Contact Information This section contains detailed information concerning EDI Customer Service. 5.1. Gainwell Technologies EDI Helpdesk and EDI Technical Assistance 1 (866) 686-4272 option 2, or e-mail idedisupport gainwelltechnologies.com. 5.2. Provider Service Number 1 (866) 686-4272 option 3, or e-mail idproviderservices gainwelltechnologies.com. 1 Note CAQH has ruled that it is not mandatory for the receiver of an 835 to send a 999. If a 999 is sent, however, the system will accept it for processing. Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 7 of 22 5.3. Applicable Websites E-mail The Idaho Medicaid Health PAS website contains companion guides, user guides, and other information needed to download the 835 Healthcare Claim Payment Advice transaction files. Website https: www.idmedicaid.com The e-mail addresses below can be used to contact Idaho Medicaid s EDI Support, Provider Services, and Provider Enrollment departments. These groups can assist and answer questions relating to EDI file submissions, provider enrollment, and services. EDI Support idedisupport gainwelltechnologies.com Provider Services idproviderservices gainwelltechnologies.com Provider Enrollment idproviderenrollment gainwelltechnologies.com Control Segments and Envelopes 6.1. Delimiters Idaho Medicaid does not require specific values for the delimiters used in electronic transactions. The suggested values are included in the specifications below. 6.2. ISA-IEA The following ISA IEA fields are the sender and receiver specific information listed in the 835 transactions. For all other fields, please see the tables below. ISA06 Interchange Sender ID will contain ID_MES_4_MMS_IG ISA08 Interchange Receiver ID will contain the Gainwell Technologies assigned trading partner ID ISA13 Sender generated Interchange Control Number. This number will match the number in IEA02 Please refer to the tables below for the ISA-IEA-specific information for the 835. 6.3. GS-GE The following GS GE fields are the sender and receiver-specific information listed in the 835 transactions. For all other fields, please see the tables below. GS02 Interchange Sender ID will contain ID_MES_4_MMS_IG GS03 Interchange Receiver ID will contain the Gainwell Technologies assigned trading partner ID GS06 Sender generated Group Control Number. Will match the number in GE02 Please refer to the tables below for the GS-GE-specific information for the 835 transactions. 6.4. ST-SE ST02 Sender generated Transaction Set Control Number. Must match the number in SE02 Please refer to the tables below for the ST-SE-specific information for the 835 transactions. Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 8 of 22 Payer-Specific Business Rules and Limitations For Gainwell Technologies Healthcare-specific business rules and limitations associated with the ASC X12N 835 Healthcare Claim Payment Advice transaction, please refer to the tables under Section 10 below. Acknowledgments and or Reports The 835 Healthcare Claim Payment Advice transaction files are generated weekly and advise report on claims that are in their finalized status (paid, denied, reversed, etc.). Once generated, the 835 file(s) can be downloaded via the trading partner s site. The following acknowledgments reports related to the submission of EDI transactions by a trading partner are not sent out for 835 transactions. 8.1. Report Inventory (Not Sent for 835 Transactions) TA1 Interchange | /kaggle/input/edi-db/CAQH 5010 835 Companion Guide.pdf | 69f62a9d267e4454bc0b0364e4df734f | 69f62a9d267e4454bc0b0364e4df734f_2 |
(paid, denied, reversed, etc.). Once generated, the 835 file(s) can be downloaded via the trading partner s site. The following acknowledgments reports related to the submission of EDI transactions by a trading partner are not sent out for 835 transactions. 8.1. Report Inventory (Not Sent for 835 Transactions) TA1 Interchange Acknowledgment. This acknowledgment is sent if requested by setting ISA14 to 1 or if ISA14 is set to 0 and there is an error that needs to be reported 999 Functional Acknowledgment. This acknowledgment file reports any errors found while checking compliance against TR3 specifications or acceptance of an EDI transaction that meets the TR3 specifications 824 Application Advice report This transaction is not mandated by HIPAA, but will be used to report the results of data content edits of transaction sets. It is designed to report rejections based on business rules, such as invalid diagnosis codes, invalid procedure codes, and invalid provider numbers. The 824 Application Advice report does not replace the 999 or TA1 transactions and will only be generated by Health PAS if there are errors within the transaction set BRR Business Rejection Report. Health PAS also produces a readable version of the 824 called the Business Rejection Report (BRR). This report helps to facilitate the immediate correction and re-bill of claims rejected during HIPAA validation Trading Partner Agreements A trading partner agreement is comprised of the completion of the trading partner registration activities and the approval to submit or receive specific transactions. Please refer to Section 2, sub-section Trading Partner Registration, for information on how to register as a trading partner and be authorized to send receive EDI transactions. Transaction Specific Information Listed below in Figure 10-1 are the specific requirements for reading and processing an ASC X12N 835 Healthcare Claim Payment Advice transaction file returned by Gainwell Technologies. Please use these guidelines in conjunction with the official ASC X12N 835 TR3 document to read and process the downloaded 835 Healthcare Claim Payment Advice transaction files. Figure 10-1: 835 Healthcare Claim Payment Advice Page Loop ID Reference Name Codes Length Notes Comments C.3 HEAD ER ISA Interchange Control Header ISA 3 Element Separator 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 9 of 22 Page Loop ID Reference Name Codes Length Notes Comments C.4 ISA01 Authorization Information Qualifier 00 2 Element Separator 1 ISA02 Authorization Information Space Fill 10 Element Separator 1 ISA03 Security Information Qualifier 00 2 Element Separator 1 ISA04 Security Information Not Used - Filled with Spaces 10 Element Separator 1 ISA05 Interchange ID Qualifier ZZ 2 Element Separator 1 ISA06 Interchange Sender ID ID_MES_4_MMS_I G or ID_MMIS_4MOLINA or ID_MMIS_4_DXCM S 15 Element Separator 1 C.5 ISA07 Interchange ID Qualifier ZZ - Mutually Defined 2 Element Separator 1 ISA08 Interchange Receiver ID Gainwell MS assigned Trading Partner ID 15 Gainwell MS assigned at registration C.5 Element Separator 1 ISA09 Interchange Date YYMMDD 6 Element Separator 1 ISA10 Interchange Time HHMM 4 Element Separator 1 ISA11 Repetition Separator 1 Element Separator 1 ISA12 Interchange Version Number 00501 5 Element Separator 1 ISA13 Interchange Control Number Assigned by Sender 9 (must be identical to interchange trailer IEA02) Element Separator 1 C.6 ISA14 Acknowledgment Requested 0 - No Ack. Requested 1 Element Separator 1 ISA15 Usage Indicator P 1 Element Separator 1 ISA16 Component Element Separator: 1 Segment End 1 C.7 GS Functional Group Header GS 2 Element Separator 1 GS01 Functional Identifier Code HP 2 C.7 Element Separator 1 GS02 Application Sender's Code Must be identical to the value in the ISA06 6 Element Separator 1 GS03 Application Receiver's Code Gainwell MS assigned Trading Partner ID 2 15 This is assigned during trading partner registration Element Separator 1 C.8 GS04 Date CCYYMMDD 8 Element Separator 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 10 of 22 Page Loop ID Reference Name Codes Length Notes Comments GS05 Time HHMM 4 8 Time based on a 24- hour clock Element Separator 1 GS06 Group Control Number (Assigned by Sender) Must be identical to the value in the GS02 1 9 Element Separator 1 GS07 Responsible Agency Code X 1 2 Element Separator 1 GS08 Version Release Code 005010X221A1 1 12 Segment End 1 68 ST Transaction Set Header ST 2 Element Separator 1 ST01 Transaction Set Identification Code 835 3 Element Separator 1 ST02 Transaction Set Control Number Sequential number assigned by sender ST02 and SE02 must be identical 4 9 Segment End 1 69 HEAD ER BPR Financial Information BPR 3 70 BPR01 Transaction Handling Code I remittance information only 1 2 Element Separator 1 71 BPR02 Monetary Amount 1 18 Payment amount Element Separator 1 BPR03 Credit Debit Flag code C Credit - payment to the receiver s account 1 Element Separator 1 72 BPR04 Payment Method Code CHK Check BOP Financial Institution Option 3 Payment Format Code 1 10 Element Separator 1 73 BPR06 (DFI)ID Number Qualifier 01 when BPR04 BOP 2 Element Separator 1 BPR07 (DFI) Identification Number 3 12 Required when BPR04 BOP Element Separator 1 74 BPR08 Account Number Qualifier DA - Demand Deposit when BPR04 BOP 1 3 Element Separator 1 BPR09 Account Number Required when BPR04 BOP Element Separator 1 BPR10 Originating Company Identifier 10 Required when BPR04 BOP Element Separator 1 Element Separator 1 75 BPR12 (DFI) ID Number Qualifier 01 - ABATransit Routing Number Including Check Digits when BPR04 BOP 2 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 11 of 22 Page Loop ID Reference Name Codes Length Notes Comments Element Separator 1 BPR13 (DFI) Identification Number 3 12 Bank Number Element Separator 1 76 BPR14 Account Number Qualifier 1 3 Account Type Element Separator 1 BPR15 Account Number 1 35 Bank Account Number Element Separator 1 BPR16 Date CCYYMMDD 8 EFT or Check Issue Date Segment End 1 77 HEAD ER TRN Reassociation Trace Number TRN 3 Element Separator 1 TRN01 Trace Type Code 1 Current Transaction Trace Number 1 2 Element Separator 1 TRN02 Reference Identification 1 50 Check or EFT Trace | /kaggle/input/edi-db/CAQH 5010 835 Companion Guide.pdf | 69f62a9d267e4454bc0b0364e4df734f | 69f62a9d267e4454bc0b0364e4df734f_3 |
Element Separator 1 BPR16 Date CCYYMMDD 8 EFT or Check Issue Date Segment End 1 77 HEAD ER TRN Reassociation Trace Number TRN 3 Element Separator 1 TRN01 Trace Type Code 1 Current Transaction Trace Number 1 2 Element Separator 1 TRN02 Reference Identification 1 50 Check or EFT Trace Number Element Separator 1 TRN03 Originating Company Identifier 10 Payer Identifier Segment End 1 85 HEAD ER DTM Production Date DTM 3 Element Separator 1 DTM01 Date Time Qualifier 405 Production 3 Element Separator 1 86 DTM02 Date CCYYMMDD 8 Production Date Segment End 1 87 1000A N1 Payer Identification N1 2 Element Separator 1 N101 Entity Identifier Code PR Payer 2 3 Element Separator 1 N102 Name 1 60 Payer Name Segment End 1 89 1000A N3 Payer Address N3 2 Element Separator 1 N301 Address Information Payer Address 1 55 Payer Address Segment Terminator 1 90 1000A N4 Payer City, State, ZIP Code N4 2 Element Separator 1 N401 City Name 2 30 City Element Separator 1 91 N402 State or Province Code 2 State - Required if address is in the United States Element Separator 1 N403 Postal Code 3 15 Zip Code - Required if address is in the United States Segment Terminator 1 94 1000A PER Payer Business Contact Information PER 3 Element Separator 1 95 PER01 Contact Function Code CX Payers Claim Office 2 Element Separator 1 PER02 Name 1 60 Contact Name Element Separator 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 12 of 22 Page Loop ID Reference Name Codes Length Notes Comments PER03 Communication Number Qualifier TE Telephone 2 Element Separator 1 PER04 Communication Number AAABBBCCCC 1 256 Contact Number Segment End 1 97 1000A PER Payer Technical Contact Information PER 3 Element Separator 1 PER01 Contact Function Code BL Technical Department 2 Element Separator 1 98 PER02 Name 1 60 Contact Name Element Separator 1 PER03 Communication Number Qualifier TE Telephone 2 Element Separator 1 PER04 Communication Number AAABBBCCCC 1 256 Contact Number Segment Terminator 1 102 1000B N1 Payee Identification N1 2 Element Separator 1 N101 Entity Identifier Code PE Payee 2 3 Element Separator 1 N102 Name 1 60 Provider Name Element Separator 1 103 N103 Identification Code Qualifier FI Federal Taxpayer s Identification Number XX Health Care Financing Administration National Provider ID 1 2 Element Separator 1 N104 Identification Code 2 80 Identification Code - NPI or Tax ID Segment Terminator 1 104 1000B N3 Payee Address N3 2 Element Separator 1 N301 Address Information 1 55 Payee Address Line 1 Street, PO Element Separator 1 N302 Address Information 1 55 Address Line 2 - Suite Segment Terminator 1 105 1000B N4 Payee City, State, ZIP Code N4 2 Element Separator 1 N401 City Name 2 30 City Element Separator 1 106 N402 State or Province Code 2 Required if address is in the United States Element Separator 1 N403 Postal Code 3 15 Required if address is in the United States Segment Terminator 1 107 1000B REF Payee Additional identification REF 3 Reference Identification Element Separator 1 REF01 Reference Identification Qualifier TJ SSN FEIN Qualifier, If N103 XX 2 3 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 13 of 22 Page Loop ID Reference Name Codes Length Notes Comments PQ Payee Identification Molina Element Separator 1 108 REF02 Reference Identification 1 50 SSN FEIN (Tax ID) if REF01(1) TJ Segment Terminator 1 111 2000 LX Header Number LX 2 Element Separator 1 LX01 Assigned Number 1 6 Sequential Number Segment Terminator 1 123 2100 CLP Claim Payment Information CLP 3 Claim Level Data CLP01 is from CLM01 of the original claim (generated by the provider) Element Separator 1 CLP01 Claim Submitter s Identifier 1 38 Provider Claim ID (also known as the Patient Control Number) Element Separator 1 124 CLP02 Claim Status Code 1 Paid Primary 2 Paid Secondary 3 Paid Tertiary 4 Denied 22 Reversal 1 2 Element Separator 1 125 CLP03 Monetary Amount 1 18 Billed Amount The billed amount for each claim Element Separator 1 125 CLP04 Monetary Amount 1 18 Paid Amount The dollar amount included in the payment for the claim Element Separator 1 CLP05 Monetary Amount 1 18 Co-Pay Amount Element Separator 1 126 CLP06 Claim Filing Indicator Code MC - Medicaid 1 2 Code Identifying the type of claim Element Separator 1 127 CLP07 Reference Identification 1 50 Claim Internal Control Number (ICN) Element Separator 1 CLP08 Facility Code Value 1 2 Place of Service. Facility Service Code and Claim Frequency Type Code come from CLM05-1 and -2 of 837 Claim Element Separator 1 CLP09 Claim Frequency Type Code 1 Claim Frequency Type Code. Facility Service Code and Claim Frequency Type Code come from CLM05-1 and -2 of 837 Claim Segment Terminator 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 14 of 22 Page Loop ID Reference Name Codes Length Notes Comments 129 2100 CAS Claims Adjustment CAS 3 Claim Adjustment (see note at end of CAS segment) Element Separator 1 131 CAS01 Claim Adjustment Group Code CO Contractual Obligations OA Other Adjustments PI Payer Initiated Reduction PR Patient Responsibility 1 2 Element Separator 1 CAS02 Claim Adjustment Reason Code 1 5 First claim adjustment reason code Element Separator 1 132 CAS03 Monetary Amount 1 18 First claim adjustment amount Element Separator 1 Element Separator 1 CAS05 Claim Adjustment Reason Code 1 5 Second claim adjustment reason code Element Separator 1 133 CAS06 Monetary Amount 1 18 Second claim adjustment amount Element Separator 1 Element Separator 1 CAS08 Claim Adjustment Reason Code 1 5 Third claim adjustment reason code Element Separator 1 CAS09 Monetary Amount 1 18 Third claim adjustment amount Element Separator 1 134 Element Separator 1 CAS11 Claim Adjustment Reason Code 1 5 Fourth claim adjustment reason code Element Separator 1 CAS12 Monetary Amount 1 18 Fourth claim adjustment amount Element Separator 1 Element Separator 1 135 CAS14 Claim Adjustment Reason Code 1 5 Fifth claim adjustment reason code Element Separator 1 CAS15 Monetary | /kaggle/input/edi-db/CAQH 5010 835 Companion Guide.pdf | 69f62a9d267e4454bc0b0364e4df734f | 69f62a9d267e4454bc0b0364e4df734f_4 |
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