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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. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount.
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. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM 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 71/125 Monetary amount MIA12 is the old capital amount.
MIA04 is the Diagnosis Related Group (DRG) amount. MIA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA05 is the Claim Payment Remark Code. See Code Source 411. MIA-06 782 Claim Disproportionate Share Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA06 is the disproportionate share amount. MIA-07 782 Claim MSP Pass-through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA07 is the Medicare Secondary Payer (MSP) pass-through amount. MIA-08 782 Claim PPS Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA08 is the total Prospective Payment System (PPS) capital amount. MIA-09 782 PPS-Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM 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 71/125 Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount.
Transaction Set or as specified by the Reference Identification Qualifier MIA05 is the Claim Payment Remark Code. See Code Source 411. MIA-06 782 Claim Disproportionate Share Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA06 is the disproportionate share amount. MIA-07 782 Claim MSP Pass-through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA07 is the Medicare Secondary Payer (MSP) pass-through amount. MIA-08 782 Claim PPS Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA08 is the total Prospective Payment System (PPS) capital amount. MIA-09 782 PPS-Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM 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 71/125 Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount.
Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA06 is the disproportionate share amount. MIA-07 782 Claim MSP Pass-through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA07 is the Medicare Secondary Payer (MSP) pass-through amount. MIA-08 782 Claim PPS Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA08 is the total Prospective Payment System (PPS) capital amount. MIA-09 782 PPS-Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM 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 71/125 Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days.
1 Max 15 Decimal number (R) Optional Monetary amount MIA07 is the Medicare Secondary Payer (MSP) pass-through amount. MIA-08 782 Claim PPS Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA08 is the total Prospective Payment System (PPS) capital amount. MIA-09 782 PPS-Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM 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 71/125 Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount.
15 Decimal number (R) Optional Monetary amount MIA08 is the total Prospective Payment System (PPS) capital amount. MIA-09 782 PPS-Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM 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 71/125 Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount.
Decimal number (R) Optional Monetary amount MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM 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 71/125 Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount.
MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM 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 71/125 Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA19 is the professional component amount billed but not payable.
portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM 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 71/125 Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA19 is the professional component amount billed but not payable. MIA-20 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1/29/25, 8:52 PM 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 72/125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA20 is the Claim Payment Remark Code.
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 71/125 Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA19 is the professional component amount billed but not payable. MIA-20 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1/29/25, 8:52 PM 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 72/125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA20 is the Claim Payment Remark Code. See Code Source 411.
Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 71/125 Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA19 is the professional component amount billed but not payable. MIA-20 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1/29/25, 8:52 PM 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 72/125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA20 is the Claim Payment Remark Code. See Code Source 411. MIA-21 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA21 is the Claim Payment Remark Code.
Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA19 is the professional component amount billed but not payable. MIA-20 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1/29/25, 8:52 PM 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 72/125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA20 is the Claim Payment Remark Code. See Code Source 411. MIA-21 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA21 is the Claim Payment Remark Code. See Code Source 411. MIA-22 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411.
Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA19 is the professional component amount billed but not payable. MIA-20 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1/29/25, 8:52 PM 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 72/125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA20 is the Claim Payment Remark Code. See Code Source 411. MIA-21 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA21 is the Claim Payment Remark Code. See Code Source 411. MIA-22 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411.
MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA19 is the professional component amount billed but not payable. MIA-20 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1/29/25, 8:52 PM 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 72/125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA20 is the Claim Payment Remark Code. See Code Source 411. MIA-21 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA21 is the Claim Payment Remark Code. See Code Source 411. MIA-22 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount.
Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA19 is the professional component amount billed but not payable. MIA-20 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1/29/25, 8:52 PM 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 72/125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA20 is the Claim Payment Remark Code. See Code Source 411. MIA-21 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA21 is the Claim Payment Remark Code. See Code Source 411. MIA-22 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1/29/25, 8:52 PM 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 73/125 MOA 0350 Detail > Header Number Loop > Claim Payment Information Loop > MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required for outpatient/professional claims where there is a need to report a Remittance Advice Remark Code at the claim level or when the payer is Medicare or Medicaid and MOA01, 02, 08 or 09 are non-zero.
a particular Transaction Set or as specified by the Reference Identification Qualifier MIA20 is the Claim Payment Remark Code. See Code Source 411. MIA-21 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA21 is the Claim Payment Remark Code. See Code Source 411. MIA-22 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1/29/25, 8:52 PM 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 73/125 MOA 0350 Detail > Header Number Loop > Claim Payment Information Loop > MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required for outpatient/professional claims where there is a need to report a Remittance Advice Remark Code at the claim level or when the payer is Medicare or Medicaid and MOA01, 02, 08 or 09 are non-zero. If not required by this implementation guide, do not send. Either MIA or MOA may appear, but not both. All situational quantities and/or monetary amounts in this segment are;required when the value of the item is different than zero.
defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA21 is the Claim Payment Remark Code. See Code Source 411. MIA-22 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1/29/25, 8:52 PM 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 73/125 MOA 0350 Detail > Header Number Loop > Claim Payment Information Loop > MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required for outpatient/professional claims where there is a need to report a Remittance Advice Remark Code at the claim level or when the payer is Medicare or Medicaid and MOA01, 02, 08 or 09 are non-zero. If not required by this implementation guide, do not send. Either MIA or MOA may appear, but not both. All situational quantities and/or monetary amounts in this segment are;required when the value of the item is different than zero. Example MOA00000000000000XXXXXXXXXXXXXXXXXXXXX000 0000000*00000000000000~ Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%) MOA01 is the reimbursement rate.
Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1/29/25, 8:52 PM 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 73/125 MOA 0350 Detail > Header Number Loop > Claim Payment Information Loop > MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required for outpatient/professional claims where there is a need to report a Remittance Advice Remark Code at the claim level or when the payer is Medicare or Medicaid and MOA01, 02, 08 or 09 are non-zero. If not required by this implementation guide, do not send. Either MIA or MOA may appear, but not both. All situational quantities and/or monetary amounts in this segment are;required when the value of the item is different than zero. Example MOA00000000000000XXXXXXXXXXXXXXXXXXXXX000 0000000*00000000000000~ Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%) MOA01 is the reimbursement rate. MOA-02 782 Claim HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount.
Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1/29/25, 8:52 PM 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 73/125 MOA 0350 Detail > Header Number Loop > Claim Payment Information Loop > MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required for outpatient/professional claims where there is a need to report a Remittance Advice Remark Code at the claim level or when the payer is Medicare or Medicaid and MOA01, 02, 08 or 09 are non-zero. If not required by this implementation guide, do not send. Either MIA or MOA may appear, but not both. All situational quantities and/or monetary amounts in this segment are;required when the value of the item is different than zero. Example MOA00000000000000XXXXXXXXXXXXXXXXXXXXX000 0000000*00000000000000~ Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%) MOA01 is the reimbursement rate. MOA-02 782 Claim HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements.
Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1/29/25, 8:52 PM 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 73/125 MOA 0350 Detail > Header Number Loop > Claim Payment Information Loop > MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required for outpatient/professional claims where there is a need to report a Remittance Advice Remark Code at the claim level or when the payer is Medicare or Medicaid and MOA01, 02, 08 or 09 are non-zero. If not required by this implementation guide, do not send. Either MIA or MOA may appear, but not both. All situational quantities and/or monetary amounts in this segment are;required when the value of the item is different than zero. Example MOA00000000000000XXXXXXXXXXXXXXXXXXXXX000 0000000*00000000000000~ Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%) MOA01 is the reimbursement rate. MOA-02 782 Claim HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411.
MOA 0350 Detail > Header Number Loop > Claim Payment Information Loop > MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required for outpatient/professional claims where there is a need to report a Remittance Advice Remark Code at the claim level or when the payer is Medicare or Medicaid and MOA01, 02, 08 or 09 are non-zero. If not required by this implementation guide, do not send. Either MIA or MOA may appear, but not both. All situational quantities and/or monetary amounts in this segment are;required when the value of the item is different than zero. Example MOA00000000000000XXXXXXXXXXXXXXXXXXXXX000 0000000*00000000000000~ Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%) MOA01 is the reimbursement rate. MOA-02 782 Claim HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411.
there is a need to report a Remittance Advice Remark Code at the claim level or when the payer is Medicare or Medicaid and MOA01, 02, 08 or 09 are non-zero. If not required by this implementation guide, do not send. Either MIA or MOA may appear, but not both. All situational quantities and/or monetary amounts in this segment are;required when the value of the item is different than zero. Example MOA00000000000000XXXXXXXXXXXXXXXXXXXXX000 0000000*00000000000000~ Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%) MOA01 is the reimbursement rate. MOA-02 782 Claim HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1/29/25, 8:52 PM 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 74/125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA05 is the Claim Payment Remark Code.
monetary amounts in this segment are;required when the value of the item is different than zero. Example MOA00000000000000XXXXXXXXXXXXXXXXXXXXX000 0000000*00000000000000~ Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%) MOA01 is the reimbursement rate. MOA-02 782 Claim HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1/29/25, 8:52 PM 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 74/125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code.
0.0 through 1.0 represents 0% through 100%) MOA01 is the reimbursement rate. MOA-02 782 Claim HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1/29/25, 8:52 PM 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 74/125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411.
Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1/29/25, 8:52 PM 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 74/125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 Claim ESRD Payment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable.
a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1/29/25, 8:52 PM 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 74/125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 Claim ESRD Payment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1/29/25, 8:52 PM 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 75/125 REF 0400 Detail > Header Number Loop > Claim Payment Information Loop > REF Other Claim Related Identification To specify identifying information Usage notes Required when additional reference numbers specific to the claim in the CLP segment are provided to identify information used in the process of adjudicating this claim.
Payment Remark Code Min 1 Max 50 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 74/125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 Claim ESRD Payment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1/29/25, 8:52 PM 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 75/125 REF 0400 Detail > Header Number Loop > Claim Payment Information Loop > REF Other Claim Related Identification To specify identifying information Usage notes Required when additional reference numbers specific to the claim in the CLP segment are provided to identify information used in the process of adjudicating this claim. If not required by this implementation guide, do not send.
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 74/125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 Claim ESRD Payment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1/29/25, 8:52 PM 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 75/125 REF 0400 Detail > Header Number Loop > Claim Payment Information Loop > REF Other Claim Related Identification To specify identifying information Usage notes Required when additional reference numbers specific to the claim in the CLP segment are provided to identify information used in the process of adjudicating this claim. If not required by this implementation guide, do not send. Example REFCEXXX~ Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1L Group or Policy Number 6P Group Number This is the Other Insured Group Number.
MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 Claim ESRD Payment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1/29/25, 8:52 PM 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 75/125 REF 0400 Detail > Header Number Loop > Claim Payment Information Loop > REF Other Claim Related Identification To specify identifying information Usage notes Required when additional reference numbers specific to the claim in the CLP segment are provided to identify information used in the process of adjudicating this claim. If not required by this implementation guide, do not send. Example REFCEXXX~ Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1L Group or Policy Number 6P Group Number This is the Other Insured Group Number. This is required when a Corrected Priority Payer is identified in the NM1 segment and the Group Number of the other insured for that payer is known.
defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 Claim ESRD Payment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1/29/25, 8:52 PM 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 75/125 REF 0400 Detail > Header Number Loop > Claim Payment Information Loop > REF Other Claim Related Identification To specify identifying information Usage notes Required when additional reference numbers specific to the claim in the CLP segment are provided to identify information used in the process of adjudicating this claim. If not required by this implementation guide, do not send. Example REFCEXXX~ Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1L Group or Policy Number 6P Group Number This is the Other Insured Group Number. This is required when a Corrected Priority Payer is identified in the NM1 segment and the Group Number of the other insured for that payer is known. 28 Employee Identification Number CE Class of Contract Code EA Medical Record Identification Number F8 Original Reference Number When this is a correction claim and CLP07 does not equal the CLP07 value from the original claim payment, one iteration of this REF segment using this qualifier is REQUIRED to identify the original claim CLP07 value in REF02.
the Claim Payment Remark Code. See Code Source 411. MOA-08 782 Claim ESRD Payment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1/29/25, 8:52 PM 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 75/125 REF 0400 Detail > Header Number Loop > Claim Payment Information Loop > REF Other Claim Related Identification To specify identifying information Usage notes Required when additional reference numbers specific to the claim in the CLP segment are provided to identify information used in the process of adjudicating this claim. If not required by this implementation guide, do not send. Example REFCEXXX~ Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1L Group or Policy Number 6P Group Number This is the Other Insured Group Number. This is required when a Corrected Priority Payer is identified in the NM1 segment and the Group Number of the other insured for that payer is known. 28 Employee Identification Number CE Class of Contract Code EA Medical Record Identification Number F8 Original Reference Number When this is a correction claim and CLP07 does not equal the CLP07 value from the original claim payment, one iteration of this REF segment using this qualifier is REQUIRED to identify the original claim CLP07 value in REF02. See section 1.10.2.8, Reversals and Corrections, for additional information.
MOA-08 782 Claim ESRD Payment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1/29/25, 8:52 PM 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 75/125 REF 0400 Detail > Header Number Loop > Claim Payment Information Loop > REF Other Claim Related Identification To specify identifying information Usage notes Required when additional reference numbers specific to the claim in the CLP segment are provided to identify information used in the process of adjudicating this claim. If not required by this implementation guide, do not send. Example REFCEXXX~ Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1L Group or Policy Number 6P Group Number This is the Other Insured Group Number. This is required when a Corrected Priority Payer is identified in the NM1 segment and the Group Number of the other insured for that payer is known. 28 Employee Identification Number CE Class of Contract Code EA Medical Record Identification Number F8 Original Reference Number When this is a correction claim and CLP07 does not equal the CLP07 value from the original claim payment, one iteration of this REF segment using this qualifier is REQUIRED to identify the original claim CLP07 value in REF02. See section 1.10.2.8, Reversals and Corrections, for additional information. TJ Federal Taxpayer's Identification Number REF-02 127 Other Claim Related Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM 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 76/125 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Claim Received Date To specify pertinent dates and times Usage notes Required whenever state or federal regulations or the provider contract mandate interest payment or prompt payment discounts based upon the receipt date of the claim by the payer.
segment are provided to identify information used in the process of adjudicating this claim. If not required by this implementation guide, do not send. Example REFCEXXX~ Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1L Group or Policy Number 6P Group Number This is the Other Insured Group Number. This is required when a Corrected Priority Payer is identified in the NM1 segment and the Group Number of the other insured for that payer is known. 28 Employee Identification Number CE Class of Contract Code EA Medical Record Identification Number F8 Original Reference Number When this is a correction claim and CLP07 does not equal the CLP07 value from the original claim payment, one iteration of this REF segment using this qualifier is REQUIRED to identify the original claim CLP07 value in REF02. See section 1.10.2.8, Reversals and Corrections, for additional information. TJ Federal Taxpayer's Identification Number REF-02 127 Other Claim Related Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM 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 76/125 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Claim Received Date To specify pertinent dates and times Usage notes Required whenever state or federal regulations or the provider contract mandate interest payment or prompt payment discounts based upon the receipt date of the claim by the payer. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
guide, do not send. Example REFCEXXX~ Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1L Group or Policy Number 6P Group Number This is the Other Insured Group Number. This is required when a Corrected Priority Payer is identified in the NM1 segment and the Group Number of the other insured for that payer is known. 28 Employee Identification Number CE Class of Contract Code EA Medical Record Identification Number F8 Original Reference Number When this is a correction claim and CLP07 does not equal the CLP07 value from the original claim payment, one iteration of this REF segment using this qualifier is REQUIRED to identify the original claim CLP07 value in REF02. See section 1.10.2.8, Reversals and Corrections, for additional information. TJ Federal Taxpayer's Identification Number REF-02 127 Other Claim Related Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM 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 76/125 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Claim Received Date To specify pertinent dates and times Usage notes Required whenever state or federal regulations or the provider contract mandate interest payment or prompt payment discounts based upon the receipt date of the claim by the payer. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example DTM05020250130~ Variants (all may be used) DTM Coverage Expiration Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the date that the claim was received by the payer.
Original Reference Number When this is a correction claim and CLP07 does not equal the CLP07 value from the original claim payment, one iteration of this REF segment using this qualifier is REQUIRED to identify the original claim CLP07 value in REF02. See section 1.10.2.8, Reversals and Corrections, for additional information. TJ Federal Taxpayer's Identification Number REF-02 127 Other Claim Related Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM 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 76/125 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Claim Received Date To specify pertinent dates and times Usage notes Required whenever state or federal regulations or the provider contract mandate interest payment or prompt payment discounts based upon the receipt date of the claim by the payer. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example DTM05020250130~ Variants (all may be used) DTM Coverage Expiration Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the date that the claim was received by the payer. 1/29/25, 8:52 PM 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 77/125 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Coverage Expiration Date To specify pertinent dates and times Usage notes Required when payment is denied because of the expiration of coverage.
Taxpayer's Identification Number REF-02 127 Other Claim Related Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM 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 76/125 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Claim Received Date To specify pertinent dates and times Usage notes Required whenever state or federal regulations or the provider contract mandate interest payment or prompt payment discounts based upon the receipt date of the claim by the payer. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example DTM05020250130~ Variants (all may be used) DTM Coverage Expiration Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the date that the claim was received by the payer. 1/29/25, 8:52 PM 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 77/125 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Coverage Expiration Date To specify pertinent dates and times Usage notes Required when payment is denied because of the expiration of coverage. If not required by this implementation guide, do not send.
1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM 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 76/125 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Claim Received Date To specify pertinent dates and times Usage notes Required whenever state or federal regulations or the provider contract mandate interest payment or prompt payment discounts based upon the receipt date of the claim by the payer. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example DTM05020250130~ Variants (all may be used) DTM Coverage Expiration Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the date that the claim was received by the payer. 1/29/25, 8:52 PM 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 77/125 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Coverage Expiration Date To specify pertinent dates and times Usage notes Required when payment is denied because of the expiration of coverage. If not required by this implementation guide, do not send. Example DTM03620250130~ Variants (all may be used) DTM Claim Received Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 036 Expiration DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the expiration date of the patient's coverage.
payment or prompt payment discounts based upon the receipt date of the claim by the payer. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example DTM05020250130~ Variants (all may be used) DTM Coverage Expiration Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the date that the claim was received by the payer. 1/29/25, 8:52 PM 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 77/125 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Coverage Expiration Date To specify pertinent dates and times Usage notes Required when payment is denied because of the expiration of coverage. If not required by this implementation guide, do not send. Example DTM03620250130~ Variants (all may be used) DTM Claim Received Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 036 Expiration DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the expiration date of the patient's coverage. 1/29/25, 8:52 PM 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 78/125 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Statement From or To Date To specify pertinent dates and times Usage notes Dates at the claim level apply to the entire claim, including all service lines.
374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the date that the claim was received by the payer. 1/29/25, 8:52 PM 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 77/125 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Coverage Expiration Date To specify pertinent dates and times Usage notes Required when payment is denied because of the expiration of coverage. If not required by this implementation guide, do not send. Example DTM03620250130~ Variants (all may be used) DTM Claim Received Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 036 Expiration DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the expiration date of the patient's coverage. 1/29/25, 8:52 PM 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 78/125 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Statement From or To Date To specify pertinent dates and times Usage notes Dates at the claim level apply to the entire claim, including all service lines. Dates at the service line level apply only to the service line where they appear. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines.
the claim was received by the payer. 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 77/125 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Coverage Expiration Date To specify pertinent dates and times Usage notes Required when payment is denied because of the expiration of coverage. If not required by this implementation guide, do not send. Example DTM03620250130~ Variants (all may be used) DTM Claim Received Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 036 Expiration DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the expiration date of the patient's coverage. 1/29/25, 8:52 PM 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 78/125 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Statement From or To Date To specify pertinent dates and times Usage notes Dates at the claim level apply to the entire claim, including all service lines. Dates at the service line level apply only to the service line where they appear. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. For retail pharmacy claims, the Claim Statement Period Start Date is equivalent to the prescription filled date. Required when the "Statement From or To Dates" are not supplied at the service (2110 loop) level.
Information Loop > DTM Coverage Expiration Date To specify pertinent dates and times Usage notes Required when payment is denied because of the expiration of coverage. If not required by this implementation guide, do not send. Example DTM03620250130~ Variants (all may be used) DTM Claim Received Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 036 Expiration DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the expiration date of the patient's coverage. 1/29/25, 8:52 PM 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 78/125 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Statement From or To Date To specify pertinent dates and times Usage notes Dates at the claim level apply to the entire claim, including all service lines. Dates at the service line level apply only to the service line where they appear. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. For retail pharmacy claims, the Claim Statement Period Start Date is equivalent to the prescription filled date. Required when the "Statement From or To Dates" are not supplied at the service (2110 loop) level. If not required by this implementation guide, may be provided at senders discretion, but cannot be required by the receiver. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed.
specifying type of date or time, or both date and time 036 Expiration DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the expiration date of the patient's coverage. 1/29/25, 8:52 PM 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 78/125 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Statement From or To Date To specify pertinent dates and times Usage notes Dates at the claim level apply to the entire claim, including all service lines. Dates at the service line level apply only to the service line where they appear. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. For retail pharmacy claims, the Claim Statement Period Start Date is equivalent to the prescription filled date. Required when the "Statement From or To Dates" are not supplied at the service (2110 loop) level. If not required by this implementation guide, may be provided at senders discretion, but cannot be required by the receiver. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM23220250130~ Variants (all may be used) DTM Claim Received Date DTM Coverage Expiration Date Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 232 Claim Statement Period Start If the claim statement period start date is conveyed without a subsequent claim statement period end date, the end date is assumed to be the same as the start date.
Information Loop > DTM Statement From or To Date To specify pertinent dates and times Usage notes Dates at the claim level apply to the entire claim, including all service lines. Dates at the service line level apply only to the service line where they appear. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. For retail pharmacy claims, the Claim Statement Period Start Date is equivalent to the prescription filled date. Required when the "Statement From or To Dates" are not supplied at the service (2110 loop) level. If not required by this implementation guide, may be provided at senders discretion, but cannot be required by the receiver. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM23220250130~ Variants (all may be used) DTM Claim Received Date DTM Coverage Expiration Date Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 232 Claim Statement Period Start If the claim statement period start date is conveyed without a subsequent claim statement period end date, the end date is assumed to be the same as the start date. This date or code 233 is required when service level dates are not provided in the remittance advice. 233 Claim Statement Period End If a claim statement period end date is conveyed without a claim statement period start date, then the start date is assumed to be different from the end date but not conveyed at the payer's discretion. See the note on code 232.
service dates are not required, but if used they override the claim dates for individual service lines. For retail pharmacy claims, the Claim Statement Period Start Date is equivalent to the prescription filled date. Required when the "Statement From or To Dates" are not supplied at the service (2110 loop) level. If not required by this implementation guide, may be provided at senders discretion, but cannot be required by the receiver. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM23220250130~ Variants (all may be used) DTM Claim Received Date DTM Coverage Expiration Date Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 232 Claim Statement Period Start If the claim statement period start date is conveyed without a subsequent claim statement period end date, the end date is assumed to be the same as the start date. This date or code 233 is required when service level dates are not provided in the remittance advice. 233 Claim Statement Period End If a claim statement period end date is conveyed without a claim statement period start date, then the start date is assumed to be different from the end date but not conveyed at the payer's discretion. See the note on code 232. DTM-02 373 Claim Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1/29/25, 8:52 PM 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 79/125 PER 0600 Detail > Header Number Loop > Claim Payment Information Loop > PER Claim Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when there is a claim specific communications contact.
DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM23220250130~ Variants (all may be used) DTM Claim Received Date DTM Coverage Expiration Date Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 232 Claim Statement Period Start If the claim statement period start date is conveyed without a subsequent claim statement period end date, the end date is assumed to be the same as the start date. This date or code 233 is required when service level dates are not provided in the remittance advice. 233 Claim Statement Period End If a claim statement period end date is conveyed without a claim statement period start date, then the start date is assumed to be different from the end date but not conveyed at the payer's discretion. See the note on code 232. DTM-02 373 Claim Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1/29/25, 8:52 PM 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 79/125 PER 0600 Detail > Header Number Loop > Claim Payment Information Loop > PER Claim Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when there is a claim specific communications contact. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC.
use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 232 Claim Statement Period Start If the claim statement period start date is conveyed without a subsequent claim statement period end date, the end date is assumed to be the same as the start date. This date or code 233 is required when service level dates are not provided in the remittance advice. 233 Claim Statement Period End If a claim statement period end date is conveyed without a claim statement period start date, then the start date is assumed to be different from the end date but not conveyed at the payer's discretion. See the note on code 232. DTM-02 373 Claim Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1/29/25, 8:52 PM 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 79/125 PER 0600 Detail > Header Number Loop > Claim Payment Information Loop > PER Claim Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when there is a claim specific communications contact. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800)555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number.
is assumed to be the same as the start date. This date or code 233 is required when service level dates are not provided in the remittance advice. 233 Claim Statement Period End If a claim statement period end date is conveyed without a claim statement period start date, then the start date is assumed to be different from the end date but not conveyed at the payer's discretion. See the note on code 232. DTM-02 373 Claim Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1/29/25, 8:52 PM 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 79/125 PER 0600 Detail > Header Number Loop > Claim Payment Information Loop > PER Claim Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when there is a claim specific communications contact. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800)555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number. Example PERCXXXXEMXXXXXXEXXXXXXEXXXX~ If either Communication Number Qualifier (PER-05) or Claim Contact Communications Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number Extension (PER-08) is present, then the other is required Max use 2 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Claim Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail 1/29/25, 8:52 PM 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 80/125 EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number.
countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800)555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number. Example PERCXXXXEMXXXXXXEXXXXXXEXXXX~ If either Communication Number Qualifier (PER-05) or Claim Contact Communications Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number Extension (PER-08) is present, then the other is required Max use 2 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Claim Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail 1/29/25, 8:52 PM 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 80/125 EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Communication Number Extension Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM 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 81/125 AMT 0620 Detail > Header Number Loop > Claim Payment Information Loop > AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only.
2 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Claim Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail 1/29/25, 8:52 PM 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 80/125 EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Communication Number Extension Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM 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 81/125 AMT 0620 Detail > Header Number Loop > Claim Payment Information Loop > AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835.
identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Claim Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail 1/29/25, 8:52 PM 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 80/125 EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Communication Number Extension Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM 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 81/125 AMT 0620 Detail > Header Number Loop > Claim Payment Information Loop > AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send/receive one AMT for each applicable non-zero value. Do not report any zero values.
Claim Office PER-02 93 Claim Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail 1/29/25, 8:52 PM 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 80/125 EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Communication Number Extension Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM 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 81/125 AMT 0620 Detail > Header Number Loop > Claim Payment Information Loop > AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send/receive one AMT for each applicable non-zero value. Do not report any zero values. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero.
name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail 1/29/25, 8:52 PM 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 80/125 EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Communication Number Extension Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM 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 81/125 AMT 0620 Detail > Header Number Loop > Claim Payment Information Loop > AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send/receive one AMT for each applicable non-zero value. Do not report any zero values. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send.
identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail 1/29/25, 8:52 PM 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 80/125 EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Communication Number Extension Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM 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 81/125 AMT 0620 Detail > Header Number Loop > Claim Payment Information Loop > AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send/receive one AMT for each applicable non-zero value. Do not report any zero values. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTZL00000~ Max use 13 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount AU Coverage Amount Use this monetary amount to report the total covered charges.
or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail 1/29/25, 8:52 PM 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 80/125 EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Communication Number Extension Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM 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 81/125 AMT 0620 Detail > Header Number Loop > Claim Payment Information Loop > AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send/receive one AMT for each applicable non-zero value. Do not report any zero values. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTZL00000~ Max use 13 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount AU Coverage Amount Use this monetary amount to report the total covered charges. This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan.
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 80/125 EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Communication Number Extension Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM 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 81/125 AMT 0620 Detail > Header Number Loop > Claim Payment Information Loop > AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send/receive one AMT for each applicable non-zero value. Do not report any zero values. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTZL00000~ Max use 13 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount AU Coverage Amount Use this monetary amount to report the total covered charges. This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan. This excludes charges considered not covered (i.e. per day television or telephone charges) but includes reductions to payments of covered services (i.e.
the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Communication Number Extension Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM 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 81/125 AMT 0620 Detail > Header Number Loop > Claim Payment Information Loop > AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send/receive one AMT for each applicable non-zero value. Do not report any zero values. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTZL00000~ Max use 13 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount AU Coverage Amount Use this monetary amount to report the total covered charges. This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan. This excludes charges considered not covered (i.e. per day television or telephone charges) but includes reductions to payments of covered services (i.e. reductions for amounts over fee schedule and patient deductibles). DY Per Day Limit F5 Patient Amount Paid Use this monetary amount for the amount the patient has already paid. I Interest See section 1.10.2.9 for additional information.
area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Communication Number Extension Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM 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 81/125 AMT 0620 Detail > Header Number Loop > Claim Payment Information Loop > AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send/receive one AMT for each applicable non-zero value. Do not report any zero values. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTZL00000~ Max use 13 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount AU Coverage Amount Use this monetary amount to report the total covered charges. This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan. This excludes charges considered not covered (i.e. per day television or telephone charges) but includes reductions to payments of covered services (i.e. reductions for amounts over fee schedule and patient deductibles). DY Per Day Limit F5 Patient Amount Paid Use this monetary amount for the amount the patient has already paid. I Interest See section 1.10.2.9 for additional information. NL Negative Ledger Balance Used only by Medicare Part A and Medicare Part B.
the type of communication number EX Telephone Extension PER-08 364 Communication Number Extension Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM 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 81/125 AMT 0620 Detail > Header Number Loop > Claim Payment Information Loop > AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send/receive one AMT for each applicable non-zero value. Do not report any zero values. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTZL00000~ Max use 13 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount AU Coverage Amount Use this monetary amount to report the total covered charges. This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan. This excludes charges considered not covered (i.e. per day television or telephone charges) but includes reductions to payments of covered services (i.e. reductions for amounts over fee schedule and patient deductibles). DY Per Day Limit F5 Patient Amount Paid Use this monetary amount for the amount the patient has already paid. I Interest See section 1.10.2.9 for additional information. NL Negative Ledger Balance Used only by Medicare Part A and Medicare Part B. ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 AMT-02 782 Claim Supplemental Information Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes 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).
applicable non-zero value. Do not report any zero values. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTZL00000~ Max use 13 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount AU Coverage Amount Use this monetary amount to report the total covered charges. This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan. This excludes charges considered not covered (i.e. per day television or telephone charges) but includes reductions to payments of covered services (i.e. reductions for amounts over fee schedule and patient deductibles). DY Per Day Limit F5 Patient Amount Paid Use this monetary amount for the amount the patient has already paid. I Interest See section 1.10.2.9 for additional information. NL Negative Ledger Balance Used only by Medicare Part A and Medicare Part B. ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 AMT-02 782 Claim Supplemental Information Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes 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.
zero values. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTZL00000~ Max use 13 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount AU Coverage Amount Use this monetary amount to report the total covered charges. This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan. This excludes charges considered not covered (i.e. per day television or telephone charges) but includes reductions to payments of covered services (i.e. reductions for amounts over fee schedule and patient deductibles). DY Per Day Limit F5 Patient Amount Paid Use this monetary amount for the amount the patient has already paid. I Interest See section 1.10.2.9 for additional information. NL Negative Ledger Balance Used only by Medicare Part A and Medicare Part B. ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 AMT-02 782 Claim Supplemental Information Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1/29/25, 8:52 PM 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 82/125 QTY 0640 Detail > Header Number Loop > Claim Payment Information Loop > QTY Claim Supplemental Information Quantity To specify quantity information Usage notes Use this segment to convey information only.
Use this monetary amount to report the total covered charges. This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan. This excludes charges considered not covered (i.e. per day television or telephone charges) but includes reductions to payments of covered services (i.e. reductions for amounts over fee schedule and patient deductibles). DY Per Day Limit F5 Patient Amount Paid Use this monetary amount for the amount the patient has already paid. I Interest See section 1.10.2.9 for additional information. NL Negative Ledger Balance Used only by Medicare Part A and Medicare Part B. ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 AMT-02 782 Claim Supplemental Information Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1/29/25, 8:52 PM 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 82/125 QTY 0640 Detail > Header Number Loop > Claim Payment Information Loop > QTY Claim Supplemental Information Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send one QTY for each non-zero value. Do not report any zero values. Required when the value of a specific quantity identified by the QTY01 qualifier is non- zero. If not required by this implementation guide, do not send.
payments of covered services (i.e. reductions for amounts over fee schedule and patient deductibles). DY Per Day Limit F5 Patient Amount Paid Use this monetary amount for the amount the patient has already paid. I Interest See section 1.10.2.9 for additional information. NL Negative Ledger Balance Used only by Medicare Part A and Medicare Part B. ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 AMT-02 782 Claim Supplemental Information Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1/29/25, 8:52 PM 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 82/125 QTY 0640 Detail > Header Number Loop > Claim Payment Information Loop > QTY Claim Supplemental Information Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send one QTY for each non-zero value. Do not report any zero values. Required when the value of a specific quantity identified by the QTY01 qualifier is non- zero. If not required by this implementation guide, do not send. Example QTYLA0000~ Max use 14 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity CA Covered - Actual CD Co-insured - Actual LA Life-time Reserve - Actual OU Outlier Days ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Claim Supplemental Information Quantity Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/29/25, 8:52 PM 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 83/125 2110 Service Payment Information Loop Max 999 Optional SVC 0700 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > SVC Service Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information.
82/125 QTY 0640 Detail > Header Number Loop > Claim Payment Information Loop > QTY Claim Supplemental Information Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send one QTY for each non-zero value. Do not report any zero values. Required when the value of a specific quantity identified by the QTY01 qualifier is non- zero. If not required by this implementation guide, do not send. Example QTYLA0000~ Max use 14 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity CA Covered - Actual CD Co-insured - Actual LA Life-time Reserve - Actual OU Outlier Days ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Claim Supplemental Information Quantity Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/29/25, 8:52 PM 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 83/125 2110 Service Payment Information Loop Max 999 Optional SVC 0700 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > SVC Service Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO78*25~). See section 1.10.2.4.1 for additional information.
Send one QTY for each non-zero value. Do not report any zero values. Required when the value of a specific quantity identified by the QTY01 qualifier is non- zero. If not required by this implementation guide, do not send. Example QTYLA0000~ Max use 14 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity CA Covered - Actual CD Co-insured - Actual LA Life-time Reserve - Actual OU Outlier Days ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Claim Supplemental Information Quantity Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/29/25, 8:52 PM 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 83/125 2110 Service Payment Information Loop Max 999 Optional SVC 0700 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > SVC Service Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO78*25~). See section 1.10.2.4.1 for additional information. See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information.
specific quantity identified by the QTY01 qualifier is non- zero. If not required by this implementation guide, do not send. Example QTYLA0000~ Max use 14 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity CA Covered - Actual CD Co-insured - Actual LA Life-time Reserve - Actual OU Outlier Days ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Claim Supplemental Information Quantity Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/29/25, 8:52 PM 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 83/125 2110 Service Payment Information Loop Max 999 Optional SVC 0700 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > SVC Service Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO78*25~). See section 1.10.2.4.1 for additional information. See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information. Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem).
Days ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Claim Supplemental Information Quantity Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/29/25, 8:52 PM 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 83/125 2110 Service Payment Information Loop Max 999 Optional SVC 0700 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > SVC Service Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO78*25~). See section 1.10.2.4.1 for additional information. See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information. Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send.
1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Claim Supplemental Information Quantity Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/29/25, 8:52 PM 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 83/125 2110 Service Payment Information Loop Max 999 Optional SVC 0700 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > SVC Service Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO7825~). See section 1.10.2.4.1 for additional information. See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information. Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send. Example SVCHP>XX>XX>XX>XX>XX0000000000000000XXXXX000 000000000000HC>XXXXXX>XX>XX>XX>XX>X0000000000~ Max use 1 Required SVC-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based.
Payment Mandate - Category 5 QTY-02 380 Claim Supplemental Information Quantity Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/29/25, 8:52 PM 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 83/125 2110 Service Payment Information Loop Max 999 Optional SVC 0700 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > SVC Service Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO7825~). See section 1.10.2.4.1 for additional information. See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information. Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send. Example SVCHP>XX>XX>XX>XX>XX0000000000000000XXXXX000 000000000000HC>XXXXXX>XX>XX>XX>XX>X0000000000~ Max use 1 Required SVC-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132).
EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 83/125 2110 Service Payment Information Loop Max 999 Optional SVC 0700 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > SVC Service Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO7825~). See section 1.10.2.4.1 for additional information. See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information. Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send. Example SVCHP>XX>XX>XX>XX>XX0000000000000000XXXXX000 000000000000HC>XXXXXX>XX>XX>XX>XX>X0000000000~ Max use 1 Required SVC-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132). Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08.
Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO7825~). See section 1.10.2.4.1 for additional information. See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information. Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send. Example SVCHP>XX>XX>XX>XX>XX0000000000000000XXXXX000 000000000000HC>XXXXXX>XX>XX>XX>XX>X0000000000~ Max use 1 Required SVC-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132). Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7.
See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO7825~). See section 1.10.2.4.1 for additional information. See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information. Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send. Example SVCHP>XX>XX>XX>XX>XX0000000000000000XXXXX000 000000000000HC>XXXXXX>XX>XX>XX>XX>X0000000000~ Max use 1 Required SVC-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132). Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7. 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 84/125 AD American Dental Association Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC.
Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information. Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send. Example SVCHP>XX>XX>XX>XX>XX0000000000000000XXXXX000 000000000000HC>XXXXXX>XX>XX>XX>XX>X*0000000000~ Max use 1 Required SVC-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132). Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7. 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 84/125 AD American Dental Association Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System.
or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send. Example SVCHP>XX>XX>XX>XX>XX0000000000000000XXXXX000 000000000000HC>XXXXXX>XX>XX>XX>XX>X*0000000000~ Max use 1 Required SVC-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132). Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7. 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 84/125 AD American Dental Association Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes C003-02 234 Adjudicated Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
Required SVC-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132). Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7. 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 84/125 AD American Dental Association Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes C003-02 234 Adjudicated Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1.
modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132). Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7. 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 84/125 AD American Dental Association Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes C003-02 234 Adjudicated Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08.
source 130) and SVC04 would be the Revenue Code (see code source 132). Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7. 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 84/125 AD American Dental Association Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes C003-02 234 Adjudicated Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08.
used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7. 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 84/125 AD American Dental Association Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes C003-02 234 Adjudicated Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08.
Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 84/125 AD American Dental Association Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes C003-02 234 Adjudicated Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08.
also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes C003-02 234 Adjudicated Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. SVC-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC02 is the submitted service charge.
Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes C003-02 234 Adjudicated Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. SVC-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC02 is the submitted service charge. 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 85/125 Usage notes Use this monetary amount for the submitted service charge amount.
5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes C003-02 234 Adjudicated Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. SVC-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC02 is the submitted service charge. 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 85/125 Usage notes Use this monetary amount for the submitted service charge amount. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements.
C003-02 represents the beginning value in the range in which the code occurs. Usage notes This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. SVC-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC02 is the submitted service charge. 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 85/125 Usage notes Use this monetary amount for the submitted service charge amount. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. SVC-03 782 Line Item Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC03 is the amount paid this service. Usage notes Use this number for the service amount paid.
Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. SVC-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC02 is the submitted service charge. 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 85/125 Usage notes Use this monetary amount for the submitted service charge amount. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. SVC-03 782 Line Item Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC03 is the amount paid this service. Usage notes Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. See 1.10.2.1, Balancing, for additional information.
in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. SVC-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC02 is the submitted service charge. 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 85/125 Usage notes Use this monetary amount for the submitted service charge amount. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. SVC-03 782 Line Item Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC03 is the amount paid this service. Usage notes Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. See 1.10.2.1, Balancing, for additional information. SVC-04 234 National Uniform Billing Committee Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service SVC04 is the National Uniform Billing Committee Revenue Code.
C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. SVC-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC02 is the submitted service charge. 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 85/125 Usage notes Use this monetary amount for the submitted service charge amount. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. SVC-03 782 Line Item Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC03 is the amount paid this service. Usage notes Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. See 1.10.2.1, Balancing, for additional information. SVC-04 234 National Uniform Billing Committee Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service SVC04 is the National Uniform Billing Committee Revenue Code. Usage notes If the original claim and adjudication only referenced an NUBC revenue code, that is supplied in SVC01 and this element is not used. SVC-05 380 Units of Service Paid Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC05 is the paid units of service.
String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. SVC-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC02 is the submitted service charge. 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 85/125 Usage notes Use this monetary amount for the submitted service charge amount. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. SVC-03 782 Line Item Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC03 is the amount paid this service. Usage notes Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. See 1.10.2.1, Balancing, for additional information. SVC-04 234 National Uniform Billing Committee Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service SVC04 is the National Uniform Billing Committee Revenue Code. Usage notes If the original claim and adjudication only referenced an NUBC revenue code, that is supplied in SVC01 and this element is not used. SVC-05 380 Units of Service Paid Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC05 is the paid units of service. Usage notes If not present, the value is assumed to be one. SVC-06 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC06 is the original submitted medical procedure.
number (R) Required Monetary amount SVC02 is the submitted service charge. 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 85/125 Usage notes Use this monetary amount for the submitted service charge amount. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. SVC-03 782 Line Item Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC03 is the amount paid this service. Usage notes Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. See 1.10.2.1, Balancing, for additional information. SVC-04 234 National Uniform Billing Committee Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service SVC04 is the National Uniform Billing Committee Revenue Code. Usage notes If the original claim and adjudication only referenced an NUBC revenue code, that is supplied in SVC01 and this element is not used. SVC-05 380 Units of Service Paid Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC05 is the paid units of service. Usage notes If not present, the value is assumed to be one. SVC-06 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC06 is the original submitted medical procedure. Usage notes Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send.
monetary amount for the submitted service charge amount. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. SVC-03 782 Line Item Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC03 is the amount paid this service. Usage notes Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. See 1.10.2.1, Balancing, for additional information. SVC-04 234 National Uniform Billing Committee Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service SVC04 is the National Uniform Billing Committee Revenue Code. Usage notes If the original claim and adjudication only referenced an NUBC revenue code, that is supplied in SVC01 and this element is not used. SVC-05 380 Units of Service Paid Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC05 is the paid units of service. Usage notes If not present, the value is assumed to be one. SVC-06 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC06 is the original submitted medical procedure. Usage notes Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send. Max use 1 Optional C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7.
Min 1 Max 15 Decimal number (R) Required Monetary amount SVC03 is the amount paid this service. Usage notes Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. See 1.10.2.1, Balancing, for additional information. SVC-04 234 National Uniform Billing Committee Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service SVC04 is the National Uniform Billing Committee Revenue Code. Usage notes If the original claim and adjudication only referenced an NUBC revenue code, that is supplied in SVC01 and this element is not used. SVC-05 380 Units of Service Paid Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC05 is the paid units of service. Usage notes If not present, the value is assumed to be one. SVC-06 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC06 is the original submitted medical procedure. Usage notes Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send. Max use 1 Optional C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7. 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 86/125 HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC.
1.10.2.1, Balancing, for additional information. SVC-04 234 National Uniform Billing Committee Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service SVC04 is the National Uniform Billing Committee Revenue Code. Usage notes If the original claim and adjudication only referenced an NUBC revenue code, that is supplied in SVC01 and this element is not used. SVC-05 380 Units of Service Paid Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC05 is the paid units of service. Usage notes If not present, the value is assumed to be one. SVC-06 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC06 is the original submitted medical procedure. Usage notes Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send. Max use 1 Optional C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7. 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 86/125 HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System.
Revenue Code. Usage notes If the original claim and adjudication only referenced an NUBC revenue code, that is supplied in SVC01 and this element is not used. SVC-05 380 Units of Service Paid Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC05 is the paid units of service. Usage notes If not present, the value is assumed to be one. SVC-06 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC06 is the original submitted medical procedure. Usage notes Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send. Max use 1 Optional C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7. 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 86/125 HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
of service. Usage notes If not present, the value is assumed to be one. SVC-06 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC06 is the original submitted medical procedure. Usage notes Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send. Max use 1 Optional C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7. 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 86/125 HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08.
the original submitted medical procedure. Usage notes Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send. Max use 1 Optional C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7. 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 86/125 HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08.
not send. Max use 1 Optional C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7. 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 86/125 HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08.
notes The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7. 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 86/125 HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08.
Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02.
Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVC-07 380 Original Units of Service Count Min 1 Max 15 Decimal number (R) Optional 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 87/125 Numeric value of quantity SVC07 is the original submitted units of service.
UB92 Codes C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVC-07 380 Original Units of Service Count Min 1 Max 15 Decimal number (R) Optional 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 87/125 Numeric value of quantity SVC07 is the original submitted units of service. 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 88/125 DTM 0800 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > DTM Service Date To specify pertinent dates and times Usage notes Dates at the service line level apply only to the service line where they appear.
defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVC-07 380 Original Units of Service Count Min 1 Max 15 Decimal number (R) Optional 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 87/125 Numeric value of quantity SVC07 is the original submitted units of service. 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 88/125 DTM 0800 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > DTM Service Date To specify pertinent dates and times Usage notes Dates at the service line level apply only to the service line where they appear. If used for inpatient claims and no service date was provided on the claim then report the through date from the claim level. When claim dates are not provided, service dates are required for every service line.

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