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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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 48/125 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 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 48/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 48/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 48/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 48/125 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. Medicare will send “MB” for Part B and DME. Medicare will send “MA” for Part A.
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. Medicare will send “MB” for Part B and DME. Medicare will send “MA” for Part A. 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) MA Medicare Part A MB Medicare Part B MC Medicaid 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.
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. Medicare will send “MB” for Part B and DME. Medicare will send “MA” for Part A. 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) MA Medicare Part A MB Medicare Part B MC Medicaid 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 when the service lines are not all for the same place of service.
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. Medicare will send “MB” for Part B and DME. Medicare will send “MA” for Part A. 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) MA Medicare Part A MB Medicare Part B MC Medicaid 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 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 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 49/125 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.
by the payer. Medicare will send “MB” for Part B and DME. Medicare will send “MA” for Part A. 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) MA Medicare Part A MB Medicare Part B MC Medicaid 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 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 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 49/125 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.
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 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 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 49/125 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 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 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 49/125 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 50/125 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.
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 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 49/125 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 50/125 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.
PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 49/125 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 50/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 50/125 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).
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 50/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 50/125 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).
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 50/125 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.
This is the adjudicated discharge fraction. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 50/125 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 CASOAXX00000000000X000000000000000XXXX00 0000000000000XXXXX00000000000000XXXX0000000 00000000000XX0000*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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 51/125 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.
(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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 51/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 51/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 51/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 51/125 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. 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 51/125 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. 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.
(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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 51/125 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. 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).
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. 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. A positive value decreases the covered days, and a negative number increases the covered days.
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. 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. A positive value decreases the covered days, and a negative number increases the covered days. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 52/125 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.
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. 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. A positive value decreases the covered days, and a negative number increases the covered days. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 52/125 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.
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. A positive value decreases the covered days, and a negative number increases the covered days. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 52/125 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.
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. A positive value decreases the covered days, and a negative number increases the covered days. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 52/125 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.
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. A positive value decreases the covered days, and a negative number increases the covered days. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 52/125 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 Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 53/125 Monetary amount CAS12 is the amount of the adjustment.
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. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 52/125 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 Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 53/125 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.
1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 52/125 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 Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 53/125 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.
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 Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 53/125 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.
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 Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 53/125 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. Usage notes See CAS03.
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 Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 53/125 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. Usage notes See CAS03. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 54/125 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. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 53/125 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. Usage notes See CAS03. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 54/125 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.
CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 53/125 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. Usage notes See CAS03. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 54/125 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 55/125 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.
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. Usage notes See CAS03. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 54/125 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 55/125 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.
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. Usage notes See CAS03. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 54/125 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 55/125 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 NM1741XXXXXXXXXXXXXXXXC*XX~ Variants (all may be used) NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber 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.
(R) Optional Monetary amount CAS18 is the amount of the adjustment. Usage notes See CAS03. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 54/125 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 55/125 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 NM1741XXXXXXXXXXXXXXXXC*XX~ Variants (all may be used) NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 56/125 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial.
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 NM1741XXXXXXXXXXXXXXXXC*XX~ Variants (all may be used) NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 56/125 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 57/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 56/125 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 57/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 56/125 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 57/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 56/125 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 57/125 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 NM1PR2XX***XVXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Crossover Carrier Name NM1 Insured or Subscriber 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 57/125 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 NM1PR2XX***XVXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Crossover Carrier Name NM1 Insured or Subscriber 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.
code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 57/125 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 NM1PR2XX***XVXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Crossover Carrier Name NM1 Insured or Subscriber 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 58/125 Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
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 NM1PR2XX***XVXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Crossover Carrier Name NM1 Insured or Subscriber 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 58/125 Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used.
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 NM1PR2XX***XVXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Crossover Carrier Name NM1 Insured or Subscriber 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 58/125 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 59/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 58/125 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 59/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 58/125 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 59/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 58/125 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 59/125 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).
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 58/125 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 59/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 58/125 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 59/125 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 NM1TT2X***PIXXXXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Insured or Subscriber 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.
XV Centers for Medicare and Medicaid Services PlanID 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 58/125 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 59/125 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 NM1TT2X***PIXXXXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Insured or Subscriber 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 59/125 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 NM1TT2X***PIXXXXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Insured or Subscriber 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) 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 60/125 PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
> 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 NM1TT2X***PIXXXXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Insured or Subscriber 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) 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 60/125 PI Payor Identification 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.
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 NM1TT2X***PIXXXXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Insured or Subscriber 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) 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 60/125 PI Payor Identification 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 61/125 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Insured or Subscriber To supply the full name of an individual or organizational entity Example NM1ILXXXXXXXXX***XXXXXXXX~ 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 If either Identification Code Qualifier (NM1-08) or Corrected Priority Payer Identification Number (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 IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Min 1 Max 1 Identifier (ID) Optional Code qualifying the type of entity NM102 qualifies NM103.
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) 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 60/125 PI Payor Identification 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 61/125 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Insured or Subscriber To supply the full name of an individual or organizational entity Example NM1ILXXXXXXXXX***XXXXXXXX~ 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 If either Identification Code Qualifier (NM1-08) or Corrected Priority Payer Identification Number (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 IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Min 1 Max 1 Identifier (ID) Optional Code qualifying the type of entity NM102 qualifies NM103. NM1-03 1035 Corrected Priority Payer 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 Min 1 Max 2 Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) NM1-09 67 Corrected Priority Payer Identification Number Min 2 Max 80 String (AN) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 62/125 Code identifying a party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 63/125 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.
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 If either Identification Code Qualifier (NM1-08) or Corrected Priority Payer Identification Number (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 IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Min 1 Max 1 Identifier (ID) Optional Code qualifying the type of entity NM102 qualifies NM103. NM1-03 1035 Corrected Priority Payer 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 Min 1 Max 2 Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) NM1-09 67 Corrected Priority Payer Identification Number Min 2 Max 80 String (AN) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 62/125 Code identifying a party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 63/125 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.
Priority Payer Identification Number (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 IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Min 1 Max 1 Identifier (ID) Optional Code qualifying the type of entity NM102 qualifies NM103. NM1-03 1035 Corrected Priority Payer 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 Min 1 Max 2 Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) NM1-09 67 Corrected Priority Payer Identification Number Min 2 Max 80 String (AN) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 62/125 Code identifying a party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 63/125 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.
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 IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Min 1 Max 1 Identifier (ID) Optional Code qualifying the type of entity NM102 qualifies NM103. NM1-03 1035 Corrected Priority Payer 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 Min 1 Max 2 Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) NM1-09 67 Corrected Priority Payer Identification Number Min 2 Max 80 String (AN) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 62/125 Code identifying a party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 63/125 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 NM1GB2XXXXXXXXXXXXXMI*XX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber 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.
Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) NM1-09 67 Corrected Priority Payer Identification Number Min 2 Max 80 String (AN) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 62/125 Code identifying a party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 63/125 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 NM1GB2XXXXXXXXXXXXXMI*XX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber 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.
Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 62/125 Code identifying a party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 63/125 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 NM1GB2XXXXXXXXXXXXXMI*XX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 64/125 Individual middle name or initial Usage notes When only one character is present this is assumed to be the middle initial.
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 NM1GB2XXXXXXXXXXXXXMI*XX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 64/125 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.
is known. If not required by this implementation guide, do not send. Example NM1GB2XXXXXXXXXXXXXMI*XX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 64/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 64/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 64/125 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 65/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 64/125 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 65/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 64/125 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 65/125 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.
PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 64/125 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 65/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 65/125 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 NM1QC1XXXXXXXXXXXXXXXXMIXXXXXXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 65/125 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 NM1QC1XXXXXXXXXXXXXXXXMIXXXXXXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 66/125 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial.
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 NM1QC1XXXXXXXXXXXXXXXXMIXXXXXXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 66/125 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.
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 NM1QC1XXXXXXXXXXXXXXXXMIXXXXXXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 66/125 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 NM1-10 706 Entity Relationship Code Min 2 Max 2 Identifier (ID) Optional Code describing entity relationship NM110 and NM111 further define the type of entity in NM101.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 66/125 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 NM1-10 706 Entity Relationship Code Min 2 Max 2 Identifier (ID) Optional Code describing entity relationship NM110 and NM111 further define the type of entity in NM101. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 67/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 66/125 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 NM1-10 706 Entity Relationship Code Min 2 Max 2 Identifier (ID) Optional Code describing entity relationship NM110 and NM111 further define the type of entity in NM101. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 67/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 66/125 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 NM1-10 706 Entity Relationship Code Min 2 Max 2 Identifier (ID) Optional Code describing entity relationship NM110 and NM111 further define the type of entity in NM101. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 67/125 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.
1 Max 25 String (AN) Optional Individual middle name or initial 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 66/125 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 NM1-10 706 Entity Relationship Code Min 2 Max 2 Identifier (ID) Optional Code describing entity relationship NM110 and NM111 further define the type of entity in NM101. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 67/125 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.
Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 66/125 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 NM1-10 706 Entity Relationship Code Min 2 Max 2 Identifier (ID) Optional Code describing entity relationship NM110 and NM111 further define the type of entity in NM101. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 67/125 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 NM1822XXXXXXXXXXXXXXXXXXXX*XXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber 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.
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 NM1-10 706 Entity Relationship Code Min 2 Max 2 Identifier (ID) Optional Code describing entity relationship NM110 and NM111 further define the type of entity in NM101. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 67/125 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 NM1822XXXXXXXXXXXXXXXXXXXX*XXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 68/125 Individual middle name or initial Usage notes If this data element is used and contains only one character, it represents the middle initial.
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 NM1822XXXXXXXXXXXXXXXXXXXX*XXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 68/125 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.
the rendering provider is different from the payee. If not required by this implementation guide, do not send. Example NM1822XXXXXXXXXXXXXXXXXXXX*XXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 68/125 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.
guide, do not send. Example NM1822XXXXXXXXXXXXXXXXXXXX*XXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 68/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 68/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 68/125 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 69/125 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.
Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 68/125 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 69/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 69/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 69/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 69/125 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 MIA0000000000000000000000000000XXXXXX00000 000000000000000000000000000000000000000 0000000000000000000000000000000000000000000 0XXXXXXXXXXX0000000000~ 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 69/125 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 MIA0000000000000000000000000000XXXXXX00000 000000000000000000000000000000000000000 0000000000000000000000000000000000000000000 0XXXXXXXXXXX0000000000~ 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 69/125 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 MIA0000000000000000000000000000XXXXXX00000 000000000000000000000000000000000000000 0000000000000000000000000000000000000000000 0XXXXXXXXXXX0000000000~ 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.
Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 69/125 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 MIA0000000000000000000000000000XXXXXX00000 000000000000000000000000000000000000000 0000000000000000000000000000000000000000000 0XXXXXXXXXXX0000000000~ 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.
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 MIA0000000000000000000000000000XXXXXX00000 000000000000000000000000000000000000000 0000000000000000000000000000000000000000000 0XXXXXXXXXXX0000000000~ 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.
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 MIA0000000000000000000000000000XXXXXX00000 000000000000000000000000000000000000000 0000000000000000000000000000000000000000000 0XXXXXXXXXXX0000000000~ 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 70/125 Monetary amount MIA04 is the Diagnosis Related Group (DRG) amount.
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 MIA0000000000000000000000000000XXXXXX00000 000000000000000000000000000000000000000 0000000000000000000000000000000000000000000 0XXXXXXXXXXX0000000000~ 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 70/125 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.
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 MIA0000000000000000000000000000XXXXXX00000 000000000000000000000000000000000000000 0000000000000000000000000000000000000000000 0XXXXXXXXXXX0000000000~ 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 70/125 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.
guide, do not send. Example MIA0000000000000000000000000000XXXXXX00000 000000000000000000000000000000000000000 0000000000000000000000000000000000000000000 0XXXXXXXXXXX0000000000~ 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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 70/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 70/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 70/125 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.
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 CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 70/125 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.

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