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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. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines.
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. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. Required when claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level.
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. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. Required when claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. For retail pharmacy claims, the service date is equivalent to the prescription filled date.
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. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. Required when claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. For retail pharmacy claims, the service date is equivalent to the prescription filled date. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed.
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. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. Required when claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. For retail pharmacy claims, the service date is equivalent to the prescription filled date. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM15120250130~ Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 150 Service Period Start This qualifier is required for reporting the beginning of multi-day services.
- 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. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. Required when claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. For retail pharmacy claims, the service date is equivalent to the prescription filled date. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM15120250130~ Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 150 Service Period Start This qualifier is required for reporting the beginning of multi-day services. If not required by this implementation guide, do not send. 151 Service Period End This qualifier is required for reporting the end of multi-day services. If not required by this implementation guide, do not send. 472 Service This qualifier is required to indicate a single day service. If not required by this implementation guide, do not send.
service date was provided on the claim then report the through date from the claim level. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. Required when claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. For retail pharmacy claims, the service date is equivalent to the prescription filled date. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM15120250130~ Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 150 Service Period Start This qualifier is required for reporting the beginning of multi-day services. If not required by this implementation guide, do not send. 151 Service Period End This qualifier is required for reporting the end of multi-day services. If not required by this implementation guide, do not send. 472 Service This qualifier is required to indicate a single day service. If not required by this implementation guide, do not send. DTM-02 373 Service Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 89/125 CAS 0900 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > CAS Service Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes An example of this level of CAS is the reduction for the part of the service charge that exceeds the usual and customary charge for the service.
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 DTM15120250130~ Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 150 Service Period Start This qualifier is required for reporting the beginning of multi-day services. If not required by this implementation guide, do not send. 151 Service Period End This qualifier is required for reporting the end of multi-day services. If not required by this implementation guide, do not send. 472 Service This qualifier is required to indicate a single day service. If not required by this implementation guide, do not send. DTM-02 373 Service Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 89/125 CAS 0900 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > CAS Service Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes An example of this level of CAS is the reduction for the part of the service charge that exceeds the usual and customary charge for the service. See sections 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02). If not required by this implementation guide, do not send.
specifying type of date or time, or both date and time 150 Service Period Start This qualifier is required for reporting the beginning of multi-day services. If not required by this implementation guide, do not send. 151 Service Period End This qualifier is required for reporting the end of multi-day services. If not required by this implementation guide, do not send. 472 Service This qualifier is required to indicate a single day service. If not required by this implementation guide, do not send. DTM-02 373 Service Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 89/125 CAS 0900 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > CAS Service Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes An example of this level of CAS is the reduction for the part of the service charge that exceeds the usual and customary charge for the service. See sections 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02). If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01).
is required for reporting the end of multi-day services. If not required by this implementation guide, do not send. 472 Service This qualifier is required to indicate a single day service. If not required by this implementation guide, do not send. DTM-02 373 Service Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 89/125 CAS 0900 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > CAS Service Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes An example of this level of CAS is the reduction for the part of the service charge that exceeds the usual and customary charge for the service. See sections 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02). If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment is reported in the first adjustment trio (CAS02-CAS04).
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 89/125 CAS 0900 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > CAS Service Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes An example of this level of CAS is the reduction for the part of the service charge that exceeds the usual and customary charge for the service. See sections 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02). If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 89/125 CAS 0900 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > CAS Service Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes An example of this level of CAS is the reduction for the part of the service charge that exceeds the usual and customary charge for the service. See sections 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02). If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CASOAXXXXX0000000000000XX00000000000000000 00XXX0000000000000000000000000X000000000000 0000000000000000XX000000000000000000000000XX XX0*00000~ If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS- 07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 90/125 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA.
(CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 90/125 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information.
Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 90/125 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer/payee agreement or a regulatory requirement has resulted in an adjustment.
Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 90/125 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer/payee agreement or a regulatory requirement has resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13.
Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 90/125 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer/payee agreement or a regulatory requirement has resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01.
If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 90/125 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer/payee agreement or a regulatory requirement has resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount.
(CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 90/125 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer/payee agreement or a regulatory requirement has resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03 and CLP04.
Max use 99 Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 90/125 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer/payee agreement or a regulatory requirement has resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03 and CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements.
If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer/payee agreement or a regulatory requirement has resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03 and CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes A positive number decreases paid units, and a negative value increases paid units.
CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer/payee agreement or a regulatory requirement has resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03 and CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes A positive number decreases paid units, and a negative value increases paid units. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 91/125 Code identifying the detailed reason the adjustment was made Usage notes See CAS02.
be reported in this order.) CO Contractual Obligations Use this code when a joint payer/payee agreement or a regulatory requirement has resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03 and CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes A positive number decreases paid units, and a negative value increases paid units. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 91/125 Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted.
Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03 and CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes A positive number decreases paid units, and a negative value increases paid units. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 91/125 Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03.
(R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03 and CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes A positive number decreases paid units, and a negative value increases paid units. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 91/125 Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04.
positive amount decreases the payment contained in SVC03 and CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes A positive number decreases paid units, and a negative value increases paid units. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 91/125 Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 92/125 See CAS02.
782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes A positive number decreases paid units, and a negative value increases paid units. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 91/125 Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 92/125 See CAS02. CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03.
adjusted. Usage notes A positive number decreases paid units, and a negative value increases paid units. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 91/125 Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 92/125 See CAS02. CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04.
1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 91/125 Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 92/125 See CAS02. CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02.
made Usage notes See CAS02. CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 92/125 See CAS02. CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04.
adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 92/125 See CAS02. CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02.
made Usage notes See CAS02. CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 92/125 See CAS02. CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 93/125 CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. Usage notes See CAS03.
Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 92/125 See CAS02. CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 93/125 CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04.
Code identifying the detailed reason the adjustment was made Usage notes 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 92/125 See CAS02. CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 93/125 CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 94/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF HealthCare Policy Identification To specify identifying information Usage notes Required when; The payment is adjusted in accordance with the Payer's published Healthcare Policy Code list and A Claim Adjustment Reason Code identified by the notation, "refer to 835 Healthcare Policy identification segment", in the Claim Adjustment Reason Code List is present in a related CAS segment and The payer has a published enumerated healthcare policy code list available to healthcare providers via an un-secure public website and The payer wishes to supply this policy detail to reduce provider inquiries.
amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 93/125 CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 94/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF HealthCare Policy Identification To specify identifying information Usage notes Required when; The payment is adjusted in accordance with the Payer's published Healthcare Policy Code list and A Claim Adjustment Reason Code identified by the notation, "refer to 835 Healthcare Policy identification segment", in the Claim Adjustment Reason Code List is present in a related CAS segment and The payer has a published enumerated healthcare policy code list available to healthcare providers via an un-secure public website and The payer wishes to supply this policy detail to reduce provider inquiries. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 93/125 CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 94/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF HealthCare Policy Identification To specify identifying information Usage notes Required when; The payment is adjusted in accordance with the Payer's published Healthcare Policy Code list and A Claim Adjustment Reason Code identified by the notation, "refer to 835 Healthcare Policy identification segment", in the Claim Adjustment Reason Code List is present in a related CAS segment and The payer has a published enumerated healthcare policy code list available to healthcare providers via an un-secure public website and The payer wishes to supply this policy detail to reduce provider inquiries. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Healthcare Policy - A clinical/statutory rule use to determine claim adjudication that cannot be explained by the sole use of a claim adjustment reason code in the CAS segment and Remittance Advise Remark code when appropriate.
Usage notes See CAS02. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 93/125 CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 94/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF HealthCare Policy Identification To specify identifying information Usage notes Required when; The payment is adjusted in accordance with the Payer's published Healthcare Policy Code list and A Claim Adjustment Reason Code identified by the notation, "refer to 835 Healthcare Policy identification segment", in the Claim Adjustment Reason Code List is present in a related CAS segment and The payer has a published enumerated healthcare policy code list available to healthcare providers via an un-secure public website and The payer wishes to supply this policy detail to reduce provider inquiries. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Healthcare Policy - A clinical/statutory rule use to determine claim adjudication that cannot be explained by the sole use of a claim adjustment reason code in the CAS segment and Remittance Advise Remark code when appropriate. The term Healthcare Policy is intended to include Medical Review Policy, Dental Policy Review, Property and Casualty Policies, Workers Comp Policies and Pharmacy Policies for example Medicare LMRP's.( Local Medicare Review policies) and NCD (National Coverage Determinations).
the amount of the adjustment. Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 94/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF HealthCare Policy Identification To specify identifying information Usage notes Required when; The payment is adjusted in accordance with the Payer's published Healthcare Policy Code list and A Claim Adjustment Reason Code identified by the notation, "refer to 835 Healthcare Policy identification segment", in the Claim Adjustment Reason Code List is present in a related CAS segment and The payer has a published enumerated healthcare policy code list available to healthcare providers via an un-secure public website and The payer wishes to supply this policy detail to reduce provider inquiries. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Healthcare Policy - A clinical/statutory rule use to determine claim adjudication that cannot be explained by the sole use of a claim adjustment reason code in the CAS segment and Remittance Advise Remark code when appropriate. The term Healthcare Policy is intended to include Medical Review Policy, Dental Policy Review, Property and Casualty Policies, Workers Comp Policies and Pharmacy Policies for example Medicare LMRP's.( Local Medicare Review policies) and NCD (National Coverage Determinations). This policy segment must not be used to provide a proprietary explanation code or reason for adjustment. Supply the Healthcare policy identifier in REF02 as provided by the payer's published Healthcare policy code list.
notes See CAS04. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 94/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF HealthCare Policy Identification To specify identifying information Usage notes Required when; The payment is adjusted in accordance with the Payer's published Healthcare Policy Code list and A Claim Adjustment Reason Code identified by the notation, "refer to 835 Healthcare Policy identification segment", in the Claim Adjustment Reason Code List is present in a related CAS segment and The payer has a published enumerated healthcare policy code list available to healthcare providers via an un-secure public website and The payer wishes to supply this policy detail to reduce provider inquiries. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Healthcare Policy - A clinical/statutory rule use to determine claim adjudication that cannot be explained by the sole use of a claim adjustment reason code in the CAS segment and Remittance Advise Remark code when appropriate. The term Healthcare Policy is intended to include Medical Review Policy, Dental Policy Review, Property and Casualty Policies, Workers Comp Policies and Pharmacy Policies for example Medicare LMRP's.( Local Medicare Review policies) and NCD (National Coverage Determinations). This policy segment must not be used to provide a proprietary explanation code or reason for adjustment. Supply the Healthcare policy identifier in REF02 as provided by the payer's published Healthcare policy code list. This policy code will be used to explain the policy used to process the claim which resulted in the adjusted payment.
1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF HealthCare Policy Identification To specify identifying information Usage notes Required when; The payment is adjusted in accordance with the Payer's published Healthcare Policy Code list and A Claim Adjustment Reason Code identified by the notation, "refer to 835 Healthcare Policy identification segment", in the Claim Adjustment Reason Code List is present in a related CAS segment and The payer has a published enumerated healthcare policy code list available to healthcare providers via an un-secure public website and The payer wishes to supply this policy detail to reduce provider inquiries. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Healthcare Policy - A clinical/statutory rule use to determine claim adjudication that cannot be explained by the sole use of a claim adjustment reason code in the CAS segment and Remittance Advise Remark code when appropriate. The term Healthcare Policy is intended to include Medical Review Policy, Dental Policy Review, Property and Casualty Policies, Workers Comp Policies and Pharmacy Policies for example Medicare LMRP's.( Local Medicare Review policies) and NCD (National Coverage Determinations). This policy segment must not be used to provide a proprietary explanation code or reason for adjustment. Supply the Healthcare policy identifier in REF02 as provided by the payer's published Healthcare policy code list. This policy code will be used to explain the policy used to process the claim which resulted in the adjusted payment. If this segment is used, the PER (Payer Web Site) segment is required to provide an un- secure WEB contact point where the provider can access the payer's enumerated, published healthcare policy.
adjusted in accordance with the Payer's published Healthcare Policy Code list and A Claim Adjustment Reason Code identified by the notation, "refer to 835 Healthcare Policy identification segment", in the Claim Adjustment Reason Code List is present in a related CAS segment and The payer has a published enumerated healthcare policy code list available to healthcare providers via an un-secure public website and The payer wishes to supply this policy detail to reduce provider inquiries. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Healthcare Policy - A clinical/statutory rule use to determine claim adjudication that cannot be explained by the sole use of a claim adjustment reason code in the CAS segment and Remittance Advise Remark code when appropriate. The term Healthcare Policy is intended to include Medical Review Policy, Dental Policy Review, Property and Casualty Policies, Workers Comp Policies and Pharmacy Policies for example Medicare LMRP's.( Local Medicare Review policies) and NCD (National Coverage Determinations). This policy segment must not be used to provide a proprietary explanation code or reason for adjustment. Supply the Healthcare policy identifier in REF02 as provided by the payer's published Healthcare policy code list. This policy code will be used to explain the policy used to process the claim which resulted in the adjusted payment. If this segment is used, the PER (Payer Web Site) segment is required to provide an un- secure WEB contact point where the provider can access the payer's enumerated, published healthcare policy. Example REF0KXX~ Variants (all may be used) REF Line Item Control Number REF Rendering Provider Information REF Service Identification Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0K Policy Form Identifying Number REF-02 127 Healthcare Policy Identification Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 95/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Line Item Control Number To specify identifying information Usage notes This is the Line Item Control Number submitted in the 837, which is utilized by the provider for tracking purposes.
is intended to include Medical Review Policy, Dental Policy Review, Property and Casualty Policies, Workers Comp Policies and Pharmacy Policies for example Medicare LMRP's.( Local Medicare Review policies) and NCD (National Coverage Determinations). This policy segment must not be used to provide a proprietary explanation code or reason for adjustment. Supply the Healthcare policy identifier in REF02 as provided by the payer's published Healthcare policy code list. This policy code will be used to explain the policy used to process the claim which resulted in the adjusted payment. If this segment is used, the PER (Payer Web Site) segment is required to provide an un- secure WEB contact point where the provider can access the payer's enumerated, published healthcare policy. Example REF0KXX~ Variants (all may be used) REF Line Item Control Number REF Rendering Provider Information REF Service Identification Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0K Policy Form Identifying Number REF-02 127 Healthcare Policy Identification Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 95/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Line Item Control Number To specify identifying information Usage notes This is the Line Item Control Number submitted in the 837, which is utilized by the provider for tracking purposes. See section 1.10.2.11 and 1.10.2.14.1 for additional information on usage with split claims or services. Note - the value in REF02 can include alpha characters.
Medicare Review policies) and NCD (National Coverage Determinations). This policy segment must not be used to provide a proprietary explanation code or reason for adjustment. Supply the Healthcare policy identifier in REF02 as provided by the payer's published Healthcare policy code list. This policy code will be used to explain the policy used to process the claim which resulted in the adjusted payment. If this segment is used, the PER (Payer Web Site) segment is required to provide an un- secure WEB contact point where the provider can access the payer's enumerated, published healthcare policy. Example REF0KXX~ Variants (all may be used) REF Line Item Control Number REF Rendering Provider Information REF Service Identification Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0K Policy Form Identifying Number REF-02 127 Healthcare Policy Identification Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 95/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Line Item Control Number To specify identifying information Usage notes This is the Line Item Control Number submitted in the 837, which is utilized by the provider for tracking purposes. See section 1.10.2.11 and 1.10.2.14.1 for additional information on usage with split claims or services. Note - the value in REF02 can include alpha characters. Required when a Line Item Control Number was received on the original claim or when claim or service line splitting has occurred. If not required by this implementation guide, do not send.
as provided by the payer's published Healthcare policy code list. This policy code will be used to explain the policy used to process the claim which resulted in the adjusted payment. If this segment is used, the PER (Payer Web Site) segment is required to provide an un- secure WEB contact point where the provider can access the payer's enumerated, published healthcare policy. Example REF0KXX~ Variants (all may be used) REF Line Item Control Number REF Rendering Provider Information REF Service Identification Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0K Policy Form Identifying Number REF-02 127 Healthcare Policy Identification Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 95/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Line Item Control Number To specify identifying information Usage notes This is the Line Item Control Number submitted in the 837, which is utilized by the provider for tracking purposes. See section 1.10.2.11 and 1.10.2.14.1 for additional information on usage with split claims or services. Note - the value in REF02 can include alpha characters. Required when a Line Item Control Number was received on the original claim or when claim or service line splitting has occurred. If not required by this implementation guide, do not send. Example REF6RXXXX~ Variants (all may be used) REF HealthCare Policy Identification REF Rendering Provider Information REF Service Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 96/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Rendering Provider Information To specify identifying information Usage notes Required when the rendering provider for this service is different than the rendering provider applicable at the claim level.
1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 95/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Line Item Control Number To specify identifying information Usage notes This is the Line Item Control Number submitted in the 837, which is utilized by the provider for tracking purposes. See section 1.10.2.11 and 1.10.2.14.1 for additional information on usage with split claims or services. Note - the value in REF02 can include alpha characters. Required when a Line Item Control Number was received on the original claim or when claim or service line splitting has occurred. If not required by this implementation guide, do not send. Example REF6RXXXX~ Variants (all may be used) REF HealthCare Policy Identification REF Rendering Provider Information REF Service Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 96/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Rendering Provider Information To specify identifying information Usage notes Required when the rendering provider for this service is different than the rendering provider applicable at the claim level. If not required by this implementation guide, do not send.
(X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 95/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Line Item Control Number To specify identifying information Usage notes This is the Line Item Control Number submitted in the 837, which is utilized by the provider for tracking purposes. See section 1.10.2.11 and 1.10.2.14.1 for additional information on usage with split claims or services. Note - the value in REF02 can include alpha characters. Required when a Line Item Control Number was received on the original claim or when claim or service line splitting has occurred. If not required by this implementation guide, do not send. Example REF6RXXXX~ Variants (all may be used) REF HealthCare Policy Identification REF Rendering Provider Information REF Service Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 96/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Rendering Provider Information To specify identifying information Usage notes Required when the rendering provider for this service is different than the rendering provider applicable at the claim level. If not required by this implementation guide, do not send. Example REFHPIXXXXXX~ Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Service Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1C Medicare Provider Number HPI Centers for Medicare and Medicaid Services National Provider Identifier This qualifier is REQUIRED when the National Provider Identifier is mandated for use and the provider is a covered health care provider under that mandate.
in REF02 can include alpha characters. Required when a Line Item Control Number was received on the original claim or when claim or service line splitting has occurred. If not required by this implementation guide, do not send. Example REF6RXXXX~ Variants (all may be used) REF HealthCare Policy Identification REF Rendering Provider Information REF Service Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 96/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Rendering Provider Information To specify identifying information Usage notes Required when the rendering provider for this service is different than the rendering provider applicable at the claim level. If not required by this implementation guide, do not send. Example REFHPIXXXXXX~ Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Service Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1C Medicare Provider Number HPI Centers for Medicare and Medicaid Services National Provider Identifier This qualifier is REQUIRED when the National Provider Identifier is mandated for use and the provider is a covered health care provider under that mandate. SY Social Security Number TJ Federal Taxpayer's Identification Number REF-02 127 Rendering Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 97/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Service Identification To specify identifying information Usage notes Required when related service specific reference identifiers were used in the process of adjudicating this service.
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 96/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Rendering Provider Information To specify identifying information Usage notes Required when the rendering provider for this service is different than the rendering provider applicable at the claim level. If not required by this implementation guide, do not send. Example REFHPIXXXXXX~ Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Service Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1C Medicare Provider Number HPI Centers for Medicare and Medicaid Services National Provider Identifier This qualifier is REQUIRED when the National Provider Identifier is mandated for use and the provider is a covered health care provider under that mandate. SY Social Security Number TJ Federal Taxpayer's Identification Number REF-02 127 Rendering Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 97/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Service Identification To specify identifying information Usage notes Required when related service specific reference identifiers were used in the process of adjudicating this service. If not required by this implementation guide, do not send.
8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 96/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Rendering Provider Information To specify identifying information Usage notes Required when the rendering provider for this service is different than the rendering provider applicable at the claim level. If not required by this implementation guide, do not send. Example REFHPIXXXXXX~ Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Service Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1C Medicare Provider Number HPI Centers for Medicare and Medicaid Services National Provider Identifier This qualifier is REQUIRED when the National Provider Identifier is mandated for use and the provider is a covered health care provider under that mandate. SY Social Security Number TJ Federal Taxpayer's Identification Number REF-02 127 Rendering Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 97/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Service Identification To specify identifying information Usage notes Required when related service specific reference identifiers were used in the process of adjudicating this service. If not required by this implementation guide, do not send. Example REFRBX~ Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Rendering Provider Information Max use 8 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1S Ambulatory Patient Group (APG) Number APC Ambulatory Payment Classification LU Location Number This is the Payer's identification for the provider location.
at the claim level. If not required by this implementation guide, do not send. Example REFHPIXXXXXX~ Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Service Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1C Medicare Provider Number HPI Centers for Medicare and Medicaid Services National Provider Identifier This qualifier is REQUIRED when the National Provider Identifier is mandated for use and the provider is a covered health care provider under that mandate. SY Social Security Number TJ Federal Taxpayer's Identification Number REF-02 127 Rendering Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 97/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Service Identification To specify identifying information Usage notes Required when related service specific reference identifiers were used in the process of adjudicating this service. If not required by this implementation guide, do not send. Example REFRBX~ Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Rendering Provider Information Max use 8 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1S Ambulatory Patient Group (APG) Number APC Ambulatory Payment Classification LU Location Number This is the Payer's identification for the provider location. This is REQUIRED when the specific site of service affected the payment of the claim.
REFHPIXXXXXX~ Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Service Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1C Medicare Provider Number HPI Centers for Medicare and Medicaid Services National Provider Identifier This qualifier is REQUIRED when the National Provider Identifier is mandated for use and the provider is a covered health care provider under that mandate. SY Social Security Number TJ Federal Taxpayer's Identification Number REF-02 127 Rendering Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 97/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Service Identification To specify identifying information Usage notes Required when related service specific reference identifiers were used in the process of adjudicating this service. If not required by this implementation guide, do not send. Example REFRBX~ Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Rendering Provider Information Max use 8 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1S Ambulatory Patient Group (APG) Number APC Ambulatory Payment Classification LU Location Number This is the Payer's identification for the provider location. This is REQUIRED when the specific site of service affected the payment of the claim. RB Rate code number Rate Code Number reflects Ambulatory Surgical Center (ASC) rate for Medicare, either 0, 50, 100 or 150%.
Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1C Medicare Provider Number HPI Centers for Medicare and Medicaid Services National Provider Identifier This qualifier is REQUIRED when the National Provider Identifier is mandated for use and the provider is a covered health care provider under that mandate. SY Social Security Number TJ Federal Taxpayer's Identification Number REF-02 127 Rendering Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 97/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Service Identification To specify identifying information Usage notes Required when related service specific reference identifiers were used in the process of adjudicating this service. If not required by this implementation guide, do not send. Example REFRBX~ Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Rendering Provider Information Max use 8 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1S Ambulatory Patient Group (APG) Number APC Ambulatory Payment Classification LU Location Number This is the Payer's identification for the provider location. This is REQUIRED when the specific site of service affected the payment of the claim. RB Rate code number Rate Code Number reflects Ambulatory Surgical Center (ASC) rate for Medicare, either 0, 50, 100 or 150%. REF-02 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 98/125 AMT 1100 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > AMT Service Supplemental Amount To indicate the total monetary amount Usage notes This segment is used to convey information only.
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 97/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Service Identification To specify identifying information Usage notes Required when related service specific reference identifiers were used in the process of adjudicating this service. If not required by this implementation guide, do not send. Example REFRBX~ Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Rendering Provider Information Max use 8 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1S Ambulatory Patient Group (APG) Number APC Ambulatory Payment Classification LU Location Number This is the Payer's identification for the provider location. This is REQUIRED when the specific site of service affected the payment of the claim. RB Rate code number Rate Code Number reflects Ambulatory Surgical Center (ASC) rate for Medicare, either 0, 50, 100 or 150%. REF-02 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 98/125 AMT 1100 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > AMT Service Supplemental Amount To indicate the total monetary amount Usage notes This segment is used to convey information only. It is not part of the financial balancing of the 835.
CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 97/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Service Identification To specify identifying information Usage notes Required when related service specific reference identifiers were used in the process of adjudicating this service. If not required by this implementation guide, do not send. Example REFRBX~ Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Rendering Provider Information Max use 8 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1S Ambulatory Patient Group (APG) Number APC Ambulatory Payment Classification LU Location Number This is the Payer's identification for the provider location. This is REQUIRED when the specific site of service affected the payment of the claim. RB Rate code number Rate Code Number reflects Ambulatory Surgical Center (ASC) rate for Medicare, either 0, 50, 100 or 150%. REF-02 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 98/125 AMT 1100 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > AMT Service Supplemental Amount To indicate the total monetary amount Usage notes This segment is used to convey information only. It is not part of the financial balancing of the 835. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero.
1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Service Identification To specify identifying information Usage notes Required when related service specific reference identifiers were used in the process of adjudicating this service. If not required by this implementation guide, do not send. Example REFRBX~ Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Rendering Provider Information Max use 8 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1S Ambulatory Patient Group (APG) Number APC Ambulatory Payment Classification LU Location Number This is the Payer's identification for the provider location. This is REQUIRED when the specific site of service affected the payment of the claim. RB Rate code number Rate Code Number reflects Ambulatory Surgical Center (ASC) rate for Medicare, either 0, 50, 100 or 150%. REF-02 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 98/125 AMT 1100 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > AMT Service Supplemental Amount To indicate the total monetary amount Usage notes This segment is used to convey information only. It is not part of the financial balancing of the 835. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send.
Loop > Service Payment Information Loop > REF Service Identification To specify identifying information Usage notes Required when related service specific reference identifiers were used in the process of adjudicating this service. If not required by this implementation guide, do not send. Example REFRBX~ Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Rendering Provider Information Max use 8 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1S Ambulatory Patient Group (APG) Number APC Ambulatory Payment Classification LU Location Number This is the Payer's identification for the provider location. This is REQUIRED when the specific site of service affected the payment of the claim. RB Rate code number Rate Code Number reflects Ambulatory Surgical Center (ASC) rate for Medicare, either 0, 50, 100 or 150%. REF-02 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 98/125 AMT 1100 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > AMT Service Supplemental Amount To indicate the total monetary amount Usage notes This segment is used to convey information only. It is not part of the financial balancing of the 835. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTZM00000000~ Max use 9 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount B6 Allowed - Actual Allowed amount is the amount the payer deems payable prior to considering patient responsibility.
this implementation guide, do not send. Example REFRBX~ Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Rendering Provider Information Max use 8 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1S Ambulatory Patient Group (APG) Number APC Ambulatory Payment Classification LU Location Number This is the Payer's identification for the provider location. This is REQUIRED when the specific site of service affected the payment of the claim. RB Rate code number Rate Code Number reflects Ambulatory Surgical Center (ASC) rate for Medicare, either 0, 50, 100 or 150%. REF-02 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 98/125 AMT 1100 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > AMT Service Supplemental Amount To indicate the total monetary amount Usage notes This segment is used to convey information only. It is not part of the financial balancing of the 835. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTZM00000000~ Max use 9 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount B6 Allowed - Actual Allowed amount is the amount the payer deems payable prior to considering patient responsibility. KH Deduction Amount Late Filing Reduction ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 AMT-02 782 Service Supplemental Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point).
150%. REF-02 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 98/125 AMT 1100 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > AMT Service Supplemental Amount To indicate the total monetary amount Usage notes This segment is used to convey information only. It is not part of the financial balancing of the 835. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTZM00000000~ Max use 9 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount B6 Allowed - Actual Allowed amount is the amount the payer deems payable prior to considering patient responsibility. KH Deduction Amount Late Filing Reduction ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 AMT-02 782 Service Supplemental Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements.
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 98/125 AMT 1100 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > AMT Service Supplemental Amount To indicate the total monetary amount Usage notes This segment is used to convey information only. It is not part of the financial balancing of the 835. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTZM00000000~ Max use 9 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount B6 Allowed - Actual Allowed amount is the amount the payer deems payable prior to considering patient responsibility. KH Deduction Amount Late Filing Reduction ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 AMT-02 782 Service Supplemental Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 99/125 QTY 1200 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > QTY Service Supplemental Quantity To specify quantity information Usage notes Use this segment to convey information only.
Service Payment Information Loop > AMT Service Supplemental Amount To indicate the total monetary amount Usage notes This segment is used to convey information only. It is not part of the financial balancing of the 835. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTZM00000000~ Max use 9 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount B6 Allowed - Actual Allowed amount is the amount the payer deems payable prior to considering patient responsibility. KH Deduction Amount Late Filing Reduction ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 AMT-02 782 Service Supplemental Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 99/125 QTY 1200 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > QTY Service Supplemental Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Required when new Federal Medicare or Medicaid mandates require Quantity counts and value of specific quantities identified in the QTY01 qualifier are non-zero. If not required by this implementation guide, do not send.
identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTZM00000000~ Max use 9 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount B6 Allowed - Actual Allowed amount is the amount the payer deems payable prior to considering patient responsibility. KH Deduction Amount Late Filing Reduction ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 AMT-02 782 Service Supplemental Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 99/125 QTY 1200 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > QTY Service Supplemental Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Required when new Federal Medicare or Medicaid mandates require Quantity counts and value of specific quantities identified in the QTY01 qualifier are non-zero. If not required by this implementation guide, do not send. Example QTYZO00000000000~ Max use 6 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Service Supplemental Quantity Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 100/125 2110 Service Payment Information Loop end 2100 Claim Payment Information Loop end 2000 Header Number Loop end Detail end LQ 1300 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > LQ Health Care Remark Codes To identify standard industry codes Usage notes Use this segment to provide informational remarks only.
8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 99/125 QTY 1200 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > QTY Service Supplemental Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Required when new Federal Medicare or Medicaid mandates require Quantity counts and value of specific quantities identified in the QTY01 qualifier are non-zero. If not required by this implementation guide, do not send. Example QTYZO00000000000~ Max use 6 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Service Supplemental Quantity Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 100/125 2110 Service Payment Information Loop end 2100 Claim Payment Information Loop end 2000 Header Number Loop end Detail end LQ 1300 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > LQ Health Care Remark Codes To identify standard industry codes Usage notes Use this segment to provide informational remarks only. This segment has no impact on the actual payment. Changes in claim payment amounts are provided in the CAS segments.
Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > QTY Service Supplemental Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Required when new Federal Medicare or Medicaid mandates require Quantity counts and value of specific quantities identified in the QTY01 qualifier are non-zero. If not required by this implementation guide, do not send. Example QTYZO00000000000~ Max use 6 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Service Supplemental Quantity Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 100/125 2110 Service Payment Information Loop end 2100 Claim Payment Information Loop end 2000 Header Number Loop end Detail end LQ 1300 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > LQ Health Care Remark Codes To identify standard industry codes Usage notes Use this segment to provide informational remarks only. This segment has no impact on the actual payment. Changes in claim payment amounts are provided in the CAS segments. Required when remark codes or NCPDP Reject/Payment codes are necessary for the provider to fully understand the adjudication message for a given service line. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
Federal Medicare or Medicaid mandates require Quantity counts and value of specific quantities identified in the QTY01 qualifier are non-zero. If not required by this implementation guide, do not send. Example QTYZO00000000000~ Max use 6 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Service Supplemental Quantity Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 100/125 2110 Service Payment Information Loop end 2100 Claim Payment Information Loop end 2000 Header Number Loop end Detail end LQ 1300 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > LQ Health Care Remark Codes To identify standard industry codes Usage notes Use this segment to provide informational remarks only. This segment has no impact on the actual payment. Changes in claim payment amounts are provided in the CAS segments. Required when remark codes or NCPDP Reject/Payment codes are necessary for the provider to fully understand the adjudication message for a given service line. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example LQHEXXX~ Max use 99 Optional LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list HE Claim Payment Remark Codes LQ-02 1271 Remark Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 101/125 Summary PLB 0100 Summary > PLB Provider Adjustment To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service Usage notes These adjustments can either decrease the payment (a positive number) or increase the payment (a negative number).
Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 100/125 2110 Service Payment Information Loop end 2100 Claim Payment Information Loop end 2000 Header Number Loop end Detail end LQ 1300 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > LQ Health Care Remark Codes To identify standard industry codes Usage notes Use this segment to provide informational remarks only. This segment has no impact on the actual payment. Changes in claim payment amounts are provided in the CAS segments. Required when remark codes or NCPDP Reject/Payment codes are necessary for the provider to fully understand the adjudication message for a given service line. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example LQHEXXX~ Max use 99 Optional LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list HE Claim Payment Remark Codes LQ-02 1271 Remark Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 101/125 Summary PLB 0100 Summary > PLB Provider Adjustment To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service Usage notes These adjustments can either decrease the payment (a positive number) or increase the payment (a negative number). Zero dollar adjustments are not allowed. Some examples of PLB adjustments are a Periodic Interim Payment (loans and loan repayment) or a capitation payment.
Loop end Detail end LQ 1300 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > LQ Health Care Remark Codes To identify standard industry codes Usage notes Use this segment to provide informational remarks only. This segment has no impact on the actual payment. Changes in claim payment amounts are provided in the CAS segments. Required when remark codes or NCPDP Reject/Payment codes are necessary for the provider to fully understand the adjudication message for a given service line. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example LQHEXXX~ Max use 99 Optional LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list HE Claim Payment Remark Codes LQ-02 1271 Remark Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 101/125 Summary PLB 0100 Summary > PLB Provider Adjustment To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service Usage notes These adjustments can either decrease the payment (a positive number) or increase the payment (a negative number). Zero dollar adjustments are not allowed. Some examples of PLB adjustments are a Periodic Interim Payment (loans and loan repayment) or a capitation payment. Multiple adjustments can be placed in one PLB segment, grouped by the provider identified in PLB01 and the period identified in PLB02.
LQ Health Care Remark Codes To identify standard industry codes Usage notes Use this segment to provide informational remarks only. This segment has no impact on the actual payment. Changes in claim payment amounts are provided in the CAS segments. Required when remark codes or NCPDP Reject/Payment codes are necessary for the provider to fully understand the adjudication message for a given service line. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example LQHEXXX~ Max use 99 Optional LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list HE Claim Payment Remark Codes LQ-02 1271 Remark Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 101/125 Summary PLB 0100 Summary > PLB Provider Adjustment To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service Usage notes These adjustments can either decrease the payment (a positive number) or increase the payment (a negative number). Zero dollar adjustments are not allowed. Some examples of PLB adjustments are a Periodic Interim Payment (loans and loan repayment) or a capitation payment. Multiple adjustments can be placed in one PLB segment, grouped by the provider identified in PLB01 and the period identified in PLB02. Although the PLB reference numbers are not standardized, refer to 1.10.2.9 (Interest and Prompt Payment Discounts), 1.10.2.10 (Capitation and Related Payments or Adjustments), 1.10.2.12 (Balance Forward Processing), 1.10.2.16 (Post Payment Recovery) and 1.10.2.17 (Claim Overpayment Recovery) for code suggestions and usage guidelines.
remark codes or NCPDP Reject/Payment codes are necessary for the provider to fully understand the adjudication message for a given service line. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example LQHEXXX~ Max use 99 Optional LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list HE Claim Payment Remark Codes LQ-02 1271 Remark Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 101/125 Summary PLB 0100 Summary > PLB Provider Adjustment To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service Usage notes These adjustments can either decrease the payment (a positive number) or increase the payment (a negative number). Zero dollar adjustments are not allowed. Some examples of PLB adjustments are a Periodic Interim Payment (loans and loan repayment) or a capitation payment. Multiple adjustments can be placed in one PLB segment, grouped by the provider identified in PLB01 and the period identified in PLB02. Although the PLB reference numbers are not standardized, refer to 1.10.2.9 (Interest and Prompt Payment Discounts), 1.10.2.10 (Capitation and Related Payments or Adjustments), 1.10.2.12 (Balance Forward Processing), 1.10.2.16 (Post Payment Recovery) and 1.10.2.17 (Claim Overpayment Recovery) for code suggestions and usage guidelines. The codes and notations under PLB03 and its components apply equally to PLB05, 07, 09, 11 and 13. Required when reporting adjustments to the actual payment that are NOT specific to a particular claim or service.
but cannot be required by the receiver. Example LQHEXXX~ Max use 99 Optional LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list HE Claim Payment Remark Codes LQ-02 1271 Remark Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 101/125 Summary PLB 0100 Summary > PLB Provider Adjustment To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service Usage notes These adjustments can either decrease the payment (a positive number) or increase the payment (a negative number). Zero dollar adjustments are not allowed. Some examples of PLB adjustments are a Periodic Interim Payment (loans and loan repayment) or a capitation payment. Multiple adjustments can be placed in one PLB segment, grouped by the provider identified in PLB01 and the period identified in PLB02. Although the PLB reference numbers are not standardized, refer to 1.10.2.9 (Interest and Prompt Payment Discounts), 1.10.2.10 (Capitation and Related Payments or Adjustments), 1.10.2.12 (Balance Forward Processing), 1.10.2.16 (Post Payment Recovery) and 1.10.2.17 (Claim Overpayment Recovery) for code suggestions and usage guidelines. The codes and notations under PLB03 and its components apply equally to PLB05, 07, 09, 11 and 13. Required when reporting adjustments to the actual payment that are NOT specific to a particular claim or service. If not required by this implementation guide, do not send.
use 99 Optional LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list HE Claim Payment Remark Codes LQ-02 1271 Remark Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 101/125 Summary PLB 0100 Summary > PLB Provider Adjustment To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service Usage notes These adjustments can either decrease the payment (a positive number) or increase the payment (a negative number). Zero dollar adjustments are not allowed. Some examples of PLB adjustments are a Periodic Interim Payment (loans and loan repayment) or a capitation payment. Multiple adjustments can be placed in one PLB segment, grouped by the provider identified in PLB01 and the period identified in PLB02. Although the PLB reference numbers are not standardized, refer to 1.10.2.9 (Interest and Prompt Payment Discounts), 1.10.2.10 (Capitation and Related Payments or Adjustments), 1.10.2.12 (Balance Forward Processing), 1.10.2.16 (Post Payment Recovery) and 1.10.2.17 (Claim Overpayment Recovery) for code suggestions and usage guidelines. The codes and notations under PLB03 and its components apply equally to PLB05, 07, 09, 11 and 13. Required when reporting adjustments to the actual payment that are NOT specific to a particular claim or service. If not required by this implementation guide, do not send. Example PLBXXXX20250130IS>XXXX0000000000XX>XXX00000 0000XX>X0000000XX>XXXX000000000000000XX>XXXX X0000XX>XXXXXX000000000000000~ If either Adjustment Identifier (PLB-05) or Provider Adjustment Amount (PLB-06) is present, then the other is required If either Adjustment Identifier (PLB-07) or Provider Adjustment Amount (PLB-08) is present, then the other is required If either Adjustment Identifier (PLB-09) or Provider Adjustment Amount (PLB-10) is present, then the other is required If either Adjustment Identifier (PLB-11) or Provider Adjustment Amount (PLB-12) is present, then the other is required If either Adjustment Identifier (PLB-13) or Provider Adjustment Amount (PLB-14) is present, then the other is required Max use >1 Optional PLB-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB01 is the provider number assigned by the payer.
of PLB adjustments are a Periodic Interim Payment (loans and loan repayment) or a capitation payment. Multiple adjustments can be placed in one PLB segment, grouped by the provider identified in PLB01 and the period identified in PLB02. Although the PLB reference numbers are not standardized, refer to 1.10.2.9 (Interest and Prompt Payment Discounts), 1.10.2.10 (Capitation and Related Payments or Adjustments), 1.10.2.12 (Balance Forward Processing), 1.10.2.16 (Post Payment Recovery) and 1.10.2.17 (Claim Overpayment Recovery) for code suggestions and usage guidelines. The codes and notations under PLB03 and its components apply equally to PLB05, 07, 09, 11 and 13. Required when reporting adjustments to the actual payment that are NOT specific to a particular claim or service. If not required by this implementation guide, do not send. Example PLBXXXX20250130IS>XXXX0000000000XX>XXX00000 0000XX>X0000000XX>XXXX000000000000000XX>XXXX X0000XX>XXXXXX000000000000000~ If either Adjustment Identifier (PLB-05) or Provider Adjustment Amount (PLB-06) is present, then the other is required If either Adjustment Identifier (PLB-07) or Provider Adjustment Amount (PLB-08) is present, then the other is required If either Adjustment Identifier (PLB-09) or Provider Adjustment Amount (PLB-10) is present, then the other is required If either Adjustment Identifier (PLB-11) or Provider Adjustment Amount (PLB-12) is present, then the other is required If either Adjustment Identifier (PLB-13) or Provider Adjustment Amount (PLB-14) is present, then the other is required Max use >1 Optional PLB-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB01 is the provider number assigned by the payer. Usage notes When the National Provider Identifier (NPI) is mandated and the provider is a covered health care provider under that mandate, this must be the NPI assigned to the provider.
PLB01 and the period identified in PLB02. Although the PLB reference numbers are not standardized, refer to 1.10.2.9 (Interest and Prompt Payment Discounts), 1.10.2.10 (Capitation and Related Payments or Adjustments), 1.10.2.12 (Balance Forward Processing), 1.10.2.16 (Post Payment Recovery) and 1.10.2.17 (Claim Overpayment Recovery) for code suggestions and usage guidelines. The codes and notations under PLB03 and its components apply equally to PLB05, 07, 09, 11 and 13. Required when reporting adjustments to the actual payment that are NOT specific to a particular claim or service. If not required by this implementation guide, do not send. Example PLBXXXX20250130IS>XXXX0000000000XX>XXX00000 0000XX>X0000000XX>XXXX000000000000000XX>XXXX X0000XX>XXXXXX000000000000000~ If either Adjustment Identifier (PLB-05) or Provider Adjustment Amount (PLB-06) is present, then the other is required If either Adjustment Identifier (PLB-07) or Provider Adjustment Amount (PLB-08) is present, then the other is required If either Adjustment Identifier (PLB-09) or Provider Adjustment Amount (PLB-10) is present, then the other is required If either Adjustment Identifier (PLB-11) or Provider Adjustment Amount (PLB-12) is present, then the other is required If either Adjustment Identifier (PLB-13) or Provider Adjustment Amount (PLB-14) is present, then the other is required Max use >1 Optional PLB-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB01 is the provider number assigned by the payer. Usage notes When the National Provider Identifier (NPI) is mandated and the provider is a covered health care provider under that mandate, this must be the NPI assigned to the provider. Until the NPI is mandated, this is the provider identifier as assigned by the payer.
refer to 1.10.2.9 (Interest and Prompt Payment Discounts), 1.10.2.10 (Capitation and Related Payments or Adjustments), 1.10.2.12 (Balance Forward Processing), 1.10.2.16 (Post Payment Recovery) and 1.10.2.17 (Claim Overpayment Recovery) for code suggestions and usage guidelines. The codes and notations under PLB03 and its components apply equally to PLB05, 07, 09, 11 and 13. Required when reporting adjustments to the actual payment that are NOT specific to a particular claim or service. If not required by this implementation guide, do not send. Example PLBXXXX20250130IS>XXXX0000000000XX>XXX00000 0000XX>X0000000XX>XXXX000000000000000XX>XXXX X0000XX>XXXXXX000000000000000~ If either Adjustment Identifier (PLB-05) or Provider Adjustment Amount (PLB-06) is present, then the other is required If either Adjustment Identifier (PLB-07) or Provider Adjustment Amount (PLB-08) is present, then the other is required If either Adjustment Identifier (PLB-09) or Provider Adjustment Amount (PLB-10) is present, then the other is required If either Adjustment Identifier (PLB-11) or Provider Adjustment Amount (PLB-12) is present, then the other is required If either Adjustment Identifier (PLB-13) or Provider Adjustment Amount (PLB-14) is present, then the other is required Max use >1 Optional PLB-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB01 is the provider number assigned by the payer. Usage notes When the National Provider Identifier (NPI) is mandated and the provider is a covered health care provider under that mandate, this must be the NPI assigned to the provider. Until the NPI is mandated, this is the provider identifier as assigned by the payer. PLB-02 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 102/125 year PLB02 is the last day of the provider's fiscal year.
Required when reporting adjustments to the actual payment that are NOT specific to a particular claim or service. If not required by this implementation guide, do not send. Example PLBXXXX20250130IS>XXXX0000000000XX>XXX00000 0000XX>X0000000XX>XXXX000000000000000XX>XXXX X0000XX>XXXXXX000000000000000~ If either Adjustment Identifier (PLB-05) or Provider Adjustment Amount (PLB-06) is present, then the other is required If either Adjustment Identifier (PLB-07) or Provider Adjustment Amount (PLB-08) is present, then the other is required If either Adjustment Identifier (PLB-09) or Provider Adjustment Amount (PLB-10) is present, then the other is required If either Adjustment Identifier (PLB-11) or Provider Adjustment Amount (PLB-12) is present, then the other is required If either Adjustment Identifier (PLB-13) or Provider Adjustment Amount (PLB-14) is present, then the other is required Max use >1 Optional PLB-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB01 is the provider number assigned by the payer. Usage notes When the National Provider Identifier (NPI) is mandated and the provider is a covered health care provider under that mandate, this must be the NPI assigned to the provider. Until the NPI is mandated, this is the provider identifier as assigned by the payer. PLB-02 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 102/125 year PLB02 is the last day of the provider's fiscal year. Usage notes This is the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known by the payer, use December 31st of the current year.
either Adjustment Identifier (PLB-05) or Provider Adjustment Amount (PLB-06) is present, then the other is required If either Adjustment Identifier (PLB-07) or Provider Adjustment Amount (PLB-08) is present, then the other is required If either Adjustment Identifier (PLB-09) or Provider Adjustment Amount (PLB-10) is present, then the other is required If either Adjustment Identifier (PLB-11) or Provider Adjustment Amount (PLB-12) is present, then the other is required If either Adjustment Identifier (PLB-13) or Provider Adjustment Amount (PLB-14) is present, then the other is required Max use >1 Optional PLB-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB01 is the provider number assigned by the payer. Usage notes When the National Provider Identifier (NPI) is mandated and the provider is a covered health care provider under that mandate, this must be the NPI assigned to the provider. Until the NPI is mandated, this is the provider identifier as assigned by the payer. PLB-02 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 102/125 year PLB02 is the last day of the provider's fiscal year. Usage notes This is the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known by the payer, use December 31st of the current year. PLB-03 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB03 is the adjustment information as defined by the payer.
is present, then the other is required If either Adjustment Identifier (PLB-09) or Provider Adjustment Amount (PLB-10) is present, then the other is required If either Adjustment Identifier (PLB-11) or Provider Adjustment Amount (PLB-12) is present, then the other is required If either Adjustment Identifier (PLB-13) or Provider Adjustment Amount (PLB-14) is present, then the other is required Max use >1 Optional PLB-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB01 is the provider number assigned by the payer. Usage notes When the National Provider Identifier (NPI) is mandated and the provider is a covered health care provider under that mandate, this must be the NPI assigned to the provider. Until the NPI is mandated, this is the provider identifier as assigned by the payer. PLB-02 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 102/125 year PLB02 is the last day of the provider's fiscal year. Usage notes This is the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known by the payer, use December 31st of the current year. PLB-03 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB03 is the adjustment information as defined by the payer. Max use 1 Required C042-01 426 Adjustment Reason Code Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment 50 Late Charge This is the Late Claim Filing Penalty or Medicare Late Cost Report Penalty.
or Provider Adjustment Amount (PLB-14) is present, then the other is required Max use >1 Optional PLB-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB01 is the provider number assigned by the payer. Usage notes When the National Provider Identifier (NPI) is mandated and the provider is a covered health care provider under that mandate, this must be the NPI assigned to the provider. Until the NPI is mandated, this is the provider identifier as assigned by the payer. PLB-02 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 102/125 year PLB02 is the last day of the provider's fiscal year. Usage notes This is the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known by the payer, use December 31st of the current year. PLB-03 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB03 is the adjustment information as defined by the payer. Max use 1 Required C042-01 426 Adjustment Reason Code Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment 50 Late Charge This is the Late Claim Filing Penalty or Medicare Late Cost Report Penalty. 51 Interest Penalty Charge This is the interest assessment for late filing. 72 Authorized Return This is the provider refund adjustment. This adjustment acknowledges a refund received from a provider for previous overpayment. PLB03-2 must always contain an identifying reference number when the value is used. PLB04 must contain a negative value.
payer. Usage notes When the National Provider Identifier (NPI) is mandated and the provider is a covered health care provider under that mandate, this must be the NPI assigned to the provider. Until the NPI is mandated, this is the provider identifier as assigned by the payer. PLB-02 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 102/125 year PLB02 is the last day of the provider's fiscal year. Usage notes This is the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known by the payer, use December 31st of the current year. PLB-03 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB03 is the adjustment information as defined by the payer. Max use 1 Required C042-01 426 Adjustment Reason Code Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment 50 Late Charge This is the Late Claim Filing Penalty or Medicare Late Cost Report Penalty. 51 Interest Penalty Charge This is the interest assessment for late filing. 72 Authorized Return This is the provider refund adjustment. This adjustment acknowledges a refund received from a provider for previous overpayment. PLB03-2 must always contain an identifying reference number when the value is used. PLB04 must contain a negative value. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. 90 Early Payment Allowance AP Acceleration of Benefits This is the accelerated payment amount or withholding.
Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 102/125 year PLB02 is the last day of the provider's fiscal year. Usage notes This is the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known by the payer, use December 31st of the current year. PLB-03 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB03 is the adjustment information as defined by the payer. Max use 1 Required C042-01 426 Adjustment Reason Code Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment 50 Late Charge This is the Late Claim Filing Penalty or Medicare Late Cost Report Penalty. 51 Interest Penalty Charge This is the interest assessment for late filing. 72 Authorized Return This is the provider refund adjustment. This adjustment acknowledges a refund received from a provider for previous overpayment. PLB03-2 must always contain an identifying reference number when the value is used. PLB04 must contain a negative value. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. 90 Early Payment Allowance AP Acceleration of Benefits This is the accelerated payment amount or withholding. Withholding or payment identification is indicated by the sign of the amount in PLB04. A positive value represents a withholding. A negative value represents a payment. B2 Rebate This adjustment code applies when a provider has remitted an overpayment to a health plan in excess of the amount requested by the health plan.
the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known by the payer, use December 31st of the current year. PLB-03 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB03 is the adjustment information as defined by the payer. Max use 1 Required C042-01 426 Adjustment Reason Code Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment 50 Late Charge This is the Late Claim Filing Penalty or Medicare Late Cost Report Penalty. 51 Interest Penalty Charge This is the interest assessment for late filing. 72 Authorized Return This is the provider refund adjustment. This adjustment acknowledges a refund received from a provider for previous overpayment. PLB03-2 must always contain an identifying reference number when the value is used. PLB04 must contain a negative value. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. 90 Early Payment Allowance AP Acceleration of Benefits This is the accelerated payment amount or withholding. Withholding or payment identification is indicated by the sign of the amount in PLB04. A positive value represents a withholding. A negative value represents a payment. B2 Rebate This adjustment code applies when a provider has remitted an overpayment to a health plan in excess of the amount requested by the health plan. The amount accepted by the health plan is reported using code 72 (Authorized Return) and offset by the amount with code WO (Overpayment Recovery). The excess returned by the provider is reported as a negative amount using code B2, returning the excess funds to the provider. B3 Recovery Allowance This represents the check received from the provider for overpayments generated by payments from other payers.
(ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment 50 Late Charge This is the Late Claim Filing Penalty or Medicare Late Cost Report Penalty. 51 Interest Penalty Charge This is the interest assessment for late filing. 72 Authorized Return This is the provider refund adjustment. This adjustment acknowledges a refund received from a provider for previous overpayment. PLB03-2 must always contain an identifying reference number when the value is used. PLB04 must contain a negative value. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. 90 Early Payment Allowance AP Acceleration of Benefits This is the accelerated payment amount or withholding. Withholding or payment identification is indicated by the sign of the amount in PLB04. A positive value represents a withholding. A negative value represents a payment. B2 Rebate This adjustment code applies when a provider has remitted an overpayment to a health plan in excess of the amount requested by the health plan. The amount accepted by the health plan is reported using code 72 (Authorized Return) and offset by the amount with code WO (Overpayment Recovery). The excess returned by the provider is reported as a negative amount using code B2, returning the excess funds to the provider. B3 Recovery Allowance This represents the check received from the provider for overpayments generated by payments from other payers. This code differs from the provider refund adjustment identified with code 72. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. BD Bad Debt Adjustment This is the bad debt passthrough. BN Bonus This is capitation specific.
received from a provider for previous overpayment. PLB03-2 must always contain an identifying reference number when the value is used. PLB04 must contain a negative value. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. 90 Early Payment Allowance AP Acceleration of Benefits This is the accelerated payment amount or withholding. Withholding or payment identification is indicated by the sign of the amount in PLB04. A positive value represents a withholding. A negative value represents a payment. B2 Rebate This adjustment code applies when a provider has remitted an overpayment to a health plan in excess of the amount requested by the health plan. The amount accepted by the health plan is reported using code 72 (Authorized Return) and offset by the amount with code WO (Overpayment Recovery). The excess returned by the provider is reported as a negative amount using code B2, returning the excess funds to the provider. B3 Recovery Allowance This represents the check received from the provider for overpayments generated by payments from other payers. This code differs from the provider refund adjustment identified with code 72. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. BD Bad Debt Adjustment This is the bad debt passthrough. BN Bonus This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. C5 Temporary Allowance This is the tentative adjustment. CS Adjustment Provide supporting identification information in PLB03-2.
adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. 90 Early Payment Allowance AP Acceleration of Benefits This is the accelerated payment amount or withholding. Withholding or payment identification is indicated by the sign of the amount in PLB04. A positive value represents a withholding. A negative value represents a payment. B2 Rebate This adjustment code applies when a provider has remitted an overpayment to a health plan in excess of the amount requested by the health plan. The amount accepted by the health plan is reported using code 72 (Authorized Return) and offset by the amount with code WO (Overpayment Recovery). The excess returned by the provider is reported as a negative amount using code B2, returning the excess funds to the provider. B3 Recovery Allowance This represents the check received from the provider for overpayments generated by payments from other payers. This code differs from the provider refund adjustment identified with code 72. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. BD Bad Debt Adjustment This is the bad debt passthrough. BN Bonus This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. C5 Temporary Allowance This is the tentative adjustment. CS Adjustment Provide supporting identification information in PLB03-2. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 103/125 CV Capital Passthru DM Direct Medical Education Passthru E3 Withholding See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information.
Acceleration of Benefits This is the accelerated payment amount or withholding. Withholding or payment identification is indicated by the sign of the amount in PLB04. A positive value represents a withholding. A negative value represents a payment. B2 Rebate This adjustment code applies when a provider has remitted an overpayment to a health plan in excess of the amount requested by the health plan. The amount accepted by the health plan is reported using code 72 (Authorized Return) and offset by the amount with code WO (Overpayment Recovery). The excess returned by the provider is reported as a negative amount using code B2, returning the excess funds to the provider. B3 Recovery Allowance This represents the check received from the provider for overpayments generated by payments from other payers. This code differs from the provider refund adjustment identified with code 72. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. BD Bad Debt Adjustment This is the bad debt passthrough. BN Bonus This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. C5 Temporary Allowance This is the tentative adjustment. CS Adjustment Provide supporting identification information in PLB03-2. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 103/125 CV Capital Passthru DM Direct Medical Education Passthru E3 Withholding See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. FB Forwarding Balance This is the balance forward. A negative value in PLB04 represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice.
payment. B2 Rebate This adjustment code applies when a provider has remitted an overpayment to a health plan in excess of the amount requested by the health plan. The amount accepted by the health plan is reported using code 72 (Authorized Return) and offset by the amount with code WO (Overpayment Recovery). The excess returned by the provider is reported as a negative amount using code B2, returning the excess funds to the provider. B3 Recovery Allowance This represents the check received from the provider for overpayments generated by payments from other payers. This code differs from the provider refund adjustment identified with code 72. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. BD Bad Debt Adjustment This is the bad debt passthrough. BN Bonus This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. C5 Temporary Allowance This is the tentative adjustment. CS Adjustment Provide supporting identification information in PLB03-2. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 103/125 CV Capital Passthru DM Direct Medical Education Passthru E3 Withholding See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. FB Forwarding Balance This is the balance forward. A negative value in PLB04 represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice. A reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information.
excess of the amount requested by the health plan. The amount accepted by the health plan is reported using code 72 (Authorized Return) and offset by the amount with code WO (Overpayment Recovery). The excess returned by the provider is reported as a negative amount using code B2, returning the excess funds to the provider. B3 Recovery Allowance This represents the check received from the provider for overpayments generated by payments from other payers. This code differs from the provider refund adjustment identified with code 72. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. BD Bad Debt Adjustment This is the bad debt passthrough. BN Bonus This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. C5 Temporary Allowance This is the tentative adjustment. CS Adjustment Provide supporting identification information in PLB03-2. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 103/125 CV Capital Passthru DM Direct Medical Education Passthru E3 Withholding See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. FB Forwarding Balance This is the balance forward. A negative value in PLB04 represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice. A reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information. GO Graduate Medical Education Passthru HM Hemophilia Clotting Factor Supplement IP Incentive Premium Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information.
code WO (Overpayment Recovery). The excess returned by the provider is reported as a negative amount using code B2, returning the excess funds to the provider. B3 Recovery Allowance This represents the check received from the provider for overpayments generated by payments from other payers. This code differs from the provider refund adjustment identified with code 72. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. BD Bad Debt Adjustment This is the bad debt passthrough. BN Bonus This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. C5 Temporary Allowance This is the tentative adjustment. CS Adjustment Provide supporting identification information in PLB03-2. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 103/125 CV Capital Passthru DM Direct Medical Education Passthru E3 Withholding See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. FB Forwarding Balance This is the balance forward. A negative value in PLB04 represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice. A reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information. GO Graduate Medical Education Passthru HM Hemophilia Clotting Factor Supplement IP Incentive Premium Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. IR Internal Revenue Service Withholding IS Interim Settlement This is the interim rate lump sum adjustment.
using code B2, returning the excess funds to the provider. B3 Recovery Allowance This represents the check received from the provider for overpayments generated by payments from other payers. This code differs from the provider refund adjustment identified with code 72. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. BD Bad Debt Adjustment This is the bad debt passthrough. BN Bonus This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. C5 Temporary Allowance This is the tentative adjustment. CS Adjustment Provide supporting identification information in PLB03-2. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 103/125 CV Capital Passthru DM Direct Medical Education Passthru E3 Withholding See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. FB Forwarding Balance This is the balance forward. A negative value in PLB04 represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice. A reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information. GO Graduate Medical Education Passthru HM Hemophilia Clotting Factor Supplement IP Incentive Premium Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. IR Internal Revenue Service Withholding IS Interim Settlement This is the interim rate lump sum adjustment. J1 Nonreimbursable This offsets the claim or service level data that reflects what could be paid if not for demonstration program or other limitation that prevents issuance of payment.
This code differs from the provider refund adjustment identified with code 72. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. BD Bad Debt Adjustment This is the bad debt passthrough. BN Bonus This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. C5 Temporary Allowance This is the tentative adjustment. CS Adjustment Provide supporting identification information in PLB03-2. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 103/125 CV Capital Passthru DM Direct Medical Education Passthru E3 Withholding See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. FB Forwarding Balance This is the balance forward. A negative value in PLB04 represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice. A reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information. GO Graduate Medical Education Passthru HM Hemophilia Clotting Factor Supplement IP Incentive Premium Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. IR Internal Revenue Service Withholding IS Interim Settlement This is the interim rate lump sum adjustment. J1 Nonreimbursable This offsets the claim or service level data that reflects what could be paid if not for demonstration program or other limitation that prevents issuance of payment. L3 Penalty This is the capitation-related penalty. Withholding or release is identified by the sign in PLB04.
offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. BD Bad Debt Adjustment This is the bad debt passthrough. BN Bonus This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. C5 Temporary Allowance This is the tentative adjustment. CS Adjustment Provide supporting identification information in PLB03-2. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 103/125 CV Capital Passthru DM Direct Medical Education Passthru E3 Withholding See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. FB Forwarding Balance This is the balance forward. A negative value in PLB04 represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice. A reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information. GO Graduate Medical Education Passthru HM Hemophilia Clotting Factor Supplement IP Incentive Premium Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. IR Internal Revenue Service Withholding IS Interim Settlement This is the interim rate lump sum adjustment. J1 Nonreimbursable This offsets the claim or service level data that reflects what could be paid if not for demonstration program or other limitation that prevents issuance of payment. L3 Penalty This is the capitation-related penalty. Withholding or release is identified by the sign in PLB04. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. L6 Interest Owed This is the interest paid on claims in this 835.
code must be directly offset. BD Bad Debt Adjustment This is the bad debt passthrough. BN Bonus This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. C5 Temporary Allowance This is the tentative adjustment. CS Adjustment Provide supporting identification information in PLB03-2. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 103/125 CV Capital Passthru DM Direct Medical Education Passthru E3 Withholding See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. FB Forwarding Balance This is the balance forward. A negative value in PLB04 represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice. A reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information. GO Graduate Medical Education Passthru HM Hemophilia Clotting Factor Supplement IP Incentive Premium Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. IR Internal Revenue Service Withholding IS Interim Settlement This is the interim rate lump sum adjustment. J1 Nonreimbursable This offsets the claim or service level data that reflects what could be paid if not for demonstration program or other limitation that prevents issuance of payment. L3 Penalty This is the capitation-related penalty. Withholding or release is identified by the sign in PLB04. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. L6 Interest Owed This is the interest paid on claims in this 835. Support the amounts related to this adjustment by 2-062 AMT amounts, where AMT01 is "I".
BN Bonus This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. C5 Temporary Allowance This is the tentative adjustment. CS Adjustment Provide supporting identification information in PLB03-2. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 103/125 CV Capital Passthru DM Direct Medical Education Passthru E3 Withholding See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. FB Forwarding Balance This is the balance forward. A negative value in PLB04 represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice. A reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information. GO Graduate Medical Education Passthru HM Hemophilia Clotting Factor Supplement IP Incentive Premium Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. IR Internal Revenue Service Withholding IS Interim Settlement This is the interim rate lump sum adjustment. J1 Nonreimbursable This offsets the claim or service level data that reflects what could be paid if not for demonstration program or other limitation that prevents issuance of payment. L3 Penalty This is the capitation-related penalty. Withholding or release is identified by the sign in PLB04. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. L6 Interest Owed This is the interest paid on claims in this 835. Support the amounts related to this adjustment by 2-062 AMT amounts, where AMT01 is "I". LE Levy IRS Levy LS Lump Sum This is the disproportionate share adjustment, indirect medical education passthrough, non-physician passthrough, passthrough lump sum adjustment, or other passthrough amount.
Provide supporting identification information in PLB03-2. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 103/125 CV Capital Passthru DM Direct Medical Education Passthru E3 Withholding See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. FB Forwarding Balance This is the balance forward. A negative value in PLB04 represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice. A reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information. GO Graduate Medical Education Passthru HM Hemophilia Clotting Factor Supplement IP Incentive Premium Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. IR Internal Revenue Service Withholding IS Interim Settlement This is the interim rate lump sum adjustment. J1 Nonreimbursable This offsets the claim or service level data that reflects what could be paid if not for demonstration program or other limitation that prevents issuance of payment. L3 Penalty This is the capitation-related penalty. Withholding or release is identified by the sign in PLB04. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. L6 Interest Owed This is the interest paid on claims in this 835. Support the amounts related to this adjustment by 2-062 AMT amounts, where AMT01 is "I". LE Levy IRS Levy LS Lump Sum This is the disproportionate share adjustment, indirect medical education passthrough, non-physician passthrough, passthrough lump sum adjustment, or other passthrough amount. The specific type of lump sum adjustment must be identified in PLB03-2.
Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 103/125 CV Capital Passthru DM Direct Medical Education Passthru E3 Withholding See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. FB Forwarding Balance This is the balance forward. A negative value in PLB04 represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice. A reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information. GO Graduate Medical Education Passthru HM Hemophilia Clotting Factor Supplement IP Incentive Premium Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. IR Internal Revenue Service Withholding IS Interim Settlement This is the interim rate lump sum adjustment. J1 Nonreimbursable This offsets the claim or service level data that reflects what could be paid if not for demonstration program or other limitation that prevents issuance of payment. L3 Penalty This is the capitation-related penalty. Withholding or release is identified by the sign in PLB04. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. L6 Interest Owed This is the interest paid on claims in this 835. Support the amounts related to this adjustment by 2-062 AMT amounts, where AMT01 is "I". LE Levy IRS Levy LS Lump Sum This is the disproportionate share adjustment, indirect medical education passthrough, non-physician passthrough, passthrough lump sum adjustment, or other passthrough amount. The specific type of lump sum adjustment must be identified in PLB03-2. OA Organ Acquisition Passthru OB Offset for Affiliated Providers Identification of the affiliated providers must be made on PLB03-2.
E3 Withholding See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. FB Forwarding Balance This is the balance forward. A negative value in PLB04 represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice. A reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information. GO Graduate Medical Education Passthru HM Hemophilia Clotting Factor Supplement IP Incentive Premium Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. IR Internal Revenue Service Withholding IS Interim Settlement This is the interim rate lump sum adjustment. J1 Nonreimbursable This offsets the claim or service level data that reflects what could be paid if not for demonstration program or other limitation that prevents issuance of payment. L3 Penalty This is the capitation-related penalty. Withholding or release is identified by the sign in PLB04. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. L6 Interest Owed This is the interest paid on claims in this 835. Support the amounts related to this adjustment by 2-062 AMT amounts, where AMT01 is "I". LE Levy IRS Levy LS Lump Sum This is the disproportionate share adjustment, indirect medical education passthrough, non-physician passthrough, passthrough lump sum adjustment, or other passthrough amount. The specific type of lump sum adjustment must be identified in PLB03-2. OA Organ Acquisition Passthru OB Offset for Affiliated Providers Identification of the affiliated providers must be made on PLB03-2. PI Periodic Interim Payment This is the periodic interim lump sum payments and reductions (PIP). The payments are made to a provider at the beginning of some period in advance of claims. These payments are advances on the expected claims for the period.
applied from a previous payment advice. A reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information. GO Graduate Medical Education Passthru HM Hemophilia Clotting Factor Supplement IP Incentive Premium Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. IR Internal Revenue Service Withholding IS Interim Settlement This is the interim rate lump sum adjustment. J1 Nonreimbursable This offsets the claim or service level data that reflects what could be paid if not for demonstration program or other limitation that prevents issuance of payment. L3 Penalty This is the capitation-related penalty. Withholding or release is identified by the sign in PLB04. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. L6 Interest Owed This is the interest paid on claims in this 835. Support the amounts related to this adjustment by 2-062 AMT amounts, where AMT01 is "I". LE Levy IRS Levy LS Lump Sum This is the disproportionate share adjustment, indirect medical education passthrough, non-physician passthrough, passthrough lump sum adjustment, or other passthrough amount. The specific type of lump sum adjustment must be identified in PLB03-2. OA Organ Acquisition Passthru OB Offset for Affiliated Providers Identification of the affiliated providers must be made on PLB03-2. PI Periodic Interim Payment This is the periodic interim lump sum payments and reductions (PIP). The payments are made to a provider at the beginning of some period in advance of claims. These payments are advances on the expected claims for the period. The reductions are the recovery of actual claims payments during the period. For instance, when a provider has a PIP payment, claims within this remittance advice covered by that payment would be offset using this code to remove the claim payment from the current check.
Capitation and Related Payments or Adjustments, for additional information. IR Internal Revenue Service Withholding IS Interim Settlement This is the interim rate lump sum adjustment. J1 Nonreimbursable This offsets the claim or service level data that reflects what could be paid if not for demonstration program or other limitation that prevents issuance of payment. L3 Penalty This is the capitation-related penalty. Withholding or release is identified by the sign in PLB04. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. L6 Interest Owed This is the interest paid on claims in this 835. Support the amounts related to this adjustment by 2-062 AMT amounts, where AMT01 is "I". LE Levy IRS Levy LS Lump Sum This is the disproportionate share adjustment, indirect medical education passthrough, non-physician passthrough, passthrough lump sum adjustment, or other passthrough amount. The specific type of lump sum adjustment must be identified in PLB03-2. OA Organ Acquisition Passthru OB Offset for Affiliated Providers Identification of the affiliated providers must be made on PLB03-2. PI Periodic Interim Payment This is the periodic interim lump sum payments and reductions (PIP). The payments are made to a provider at the beginning of some period in advance of claims. These payments are advances on the expected claims for the period. The reductions are the recovery of actual claims payments during the period. For instance, when a provider has a PIP payment, claims within this remittance advice covered by that payment would be offset using this code to remove the claim payment from the current check. The sign of the amount in PLB04 determines whether this is a payment (negative) or reduction (positive). This payment and recoupment is effectively a loan to the provider and loan repayment. See section 1.10.2.5, Advance Payments and Reconciliation, for additional information. PL Payment Final This is the final settlement. RA Retro-activity Adjustment This is capitation specific.
This is the capitation-related penalty. Withholding or release is identified by the sign in PLB04. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. L6 Interest Owed This is the interest paid on claims in this 835. Support the amounts related to this adjustment by 2-062 AMT amounts, where AMT01 is "I". LE Levy IRS Levy LS Lump Sum This is the disproportionate share adjustment, indirect medical education passthrough, non-physician passthrough, passthrough lump sum adjustment, or other passthrough amount. The specific type of lump sum adjustment must be identified in PLB03-2. OA Organ Acquisition Passthru OB Offset for Affiliated Providers Identification of the affiliated providers must be made on PLB03-2. PI Periodic Interim Payment This is the periodic interim lump sum payments and reductions (PIP). The payments are made to a provider at the beginning of some period in advance of claims. These payments are advances on the expected claims for the period. The reductions are the recovery of actual claims payments during the period. For instance, when a provider has a PIP payment, claims within this remittance advice covered by that payment would be offset using this code to remove the claim payment from the current check. The sign of the amount in PLB04 determines whether this is a payment (negative) or reduction (positive). This payment and recoupment is effectively a loan to the provider and loan repayment. See section 1.10.2.5, Advance Payments and Reconciliation, for additional information. PL Payment Final This is the final settlement. RA Retro-activity Adjustment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information.
the sign in PLB04. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. L6 Interest Owed This is the interest paid on claims in this 835. Support the amounts related to this adjustment by 2-062 AMT amounts, where AMT01 is "I". LE Levy IRS Levy LS Lump Sum This is the disproportionate share adjustment, indirect medical education passthrough, non-physician passthrough, passthrough lump sum adjustment, or other passthrough amount. The specific type of lump sum adjustment must be identified in PLB03-2. OA Organ Acquisition Passthru OB Offset for Affiliated Providers Identification of the affiliated providers must be made on PLB03-2. PI Periodic Interim Payment This is the periodic interim lump sum payments and reductions (PIP). The payments are made to a provider at the beginning of some period in advance of claims. These payments are advances on the expected claims for the period. The reductions are the recovery of actual claims payments during the period. For instance, when a provider has a PIP payment, claims within this remittance advice covered by that payment would be offset using this code to remove the claim payment from the current check. The sign of the amount in PLB04 determines whether this is a payment (negative) or reduction (positive). This payment and recoupment is effectively a loan to the provider and loan repayment. See section 1.10.2.5, Advance Payments and Reconciliation, for additional information. PL Payment Final This is the final settlement. RA Retro-activity Adjustment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. RE Return on Equity SL Student Loan Repayment 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 104/125 TL Third Party Liability This is capitation specific.
this adjustment by 2-062 AMT amounts, where AMT01 is "I". LE Levy IRS Levy LS Lump Sum This is the disproportionate share adjustment, indirect medical education passthrough, non-physician passthrough, passthrough lump sum adjustment, or other passthrough amount. The specific type of lump sum adjustment must be identified in PLB03-2. OA Organ Acquisition Passthru OB Offset for Affiliated Providers Identification of the affiliated providers must be made on PLB03-2. PI Periodic Interim Payment This is the periodic interim lump sum payments and reductions (PIP). The payments are made to a provider at the beginning of some period in advance of claims. These payments are advances on the expected claims for the period. The reductions are the recovery of actual claims payments during the period. For instance, when a provider has a PIP payment, claims within this remittance advice covered by that payment would be offset using this code to remove the claim payment from the current check. The sign of the amount in PLB04 determines whether this is a payment (negative) or reduction (positive). This payment and recoupment is effectively a loan to the provider and loan repayment. See section 1.10.2.5, Advance Payments and Reconciliation, for additional information. PL Payment Final This is the final settlement. RA Retro-activity Adjustment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. RE Return on Equity SL Student Loan Repayment 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 104/125 TL Third Party Liability This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. WO Overpayment Recovery This is the recovery of previous overpayment. An identifying number must be provided in PLB03-2.
passthrough lump sum adjustment, or other passthrough amount. The specific type of lump sum adjustment must be identified in PLB03-2. OA Organ Acquisition Passthru OB Offset for Affiliated Providers Identification of the affiliated providers must be made on PLB03-2. PI Periodic Interim Payment This is the periodic interim lump sum payments and reductions (PIP). The payments are made to a provider at the beginning of some period in advance of claims. These payments are advances on the expected claims for the period. The reductions are the recovery of actual claims payments during the period. For instance, when a provider has a PIP payment, claims within this remittance advice covered by that payment would be offset using this code to remove the claim payment from the current check. The sign of the amount in PLB04 determines whether this is a payment (negative) or reduction (positive). This payment and recoupment is effectively a loan to the provider and loan repayment. See section 1.10.2.5, Advance Payments and Reconciliation, for additional information. PL Payment Final This is the final settlement. RA Retro-activity Adjustment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. RE Return on Equity SL Student Loan Repayment 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 104/125 TL Third Party Liability This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. WO Overpayment Recovery This is the recovery of previous overpayment. An identifying number must be provided in PLB03-2. See the notes on codes 72 and B3 for additional information about balancing against a provider refund. WU Unspecified Recovery Medicare is currently using this code to represent penalty collections withheld for the IRS (an outside source).

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