X12 835 Health Care Claim Payment/Advice (X221A1)
This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Payment/Advice Transaction Set (835) for use within the context of the Electronic Data Interchange (EDI) environment.
This transaction set can be used to make a payment, send an Explanation of Benefits (EOB) remittance advice, or make a payment and send an EOB remittance advice only from a health insurer to a health care provider either directly or via a financial institution.
- ~ Segment
- * Element
- > Component
- ^ Repetition
Interchange Control Header
To start and identify an interchange of zero or more functional groups and interchange-related control segments
Code identifying the type of information in the Authorization Information
- 00
- No Authorization Information Present (No Meaningful Information in I02)
Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)
Code identifying the type of information in the Security Information
- 00
- No Security Information Present (No Meaningful Information in I04)
This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them
Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator
- ^
- Repetition Separator
Code specifying the version number of the interchange control segments
- 00501
- Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
A control number assigned by the interchange sender
Code indicating sender's request for an interchange acknowledgment
- 0
- No Interchange Acknowledgment Requested
- 1
- Interchange Acknowledgment Requested (TA1)
Code indicating whether data enclosed by this interchange envelope is test, production or information
- I
- Information
- P
- Production Data
- T
- Test Data
Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator
- >
- Component Element Separator
Functional Group Header
To indicate the beginning of a functional group and to provide control information
Code identifying a group of application related transaction sets
- HP
- Health Care Claim Payment/Advice (835)
Code identifying party sending transmission; codes agreed to by trading partners
Code identifying party receiving transmission; codes agreed to by trading partners
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
Assigned number originated and maintained by the sender
Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480
- T
- Transportation Data Coordinating Committee (TDCC)
- X
- Accredited Standards Committee X12
Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed
- 005010X221A1
- ANSI ASC X12.835 Health Care Claim Payment/Advice (835) mandated under HIPAA through June 2010
Heading
Transaction Set Header
To indicate the start of a transaction set and to assign a control number
Code uniquely identifying a Transaction Set
- The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
- The only valid value within this transaction set for ST01 is 835.
- 835
- Health Care Claim Payment/Advice
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- The Transaction Set Control Numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Start with a number, for example 0001, and increment from there. This number must be unique within a specific group and interchange, but it can be repeated in other groups and interchanges.
Financial Information
To indicate the beginning of a Payment Order/Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and/or information from payer to payee to occur
- Use the BPR to address a single payment to a single payee. A payee may represent a single provider, a provider group, or multiple providers in a chain. The BPR contains mandatory information, even when it is not being used to move funds electronically.
Code designating the action to be taken by all parties
- I
- Remittance Information Only
Use this code to indicate to the payee that the remittance detail is moving separately from the payment.
Monetary amount
- BPR02 specifies the payment amount.
- Use BPR02 for the total payment amount for this 835. The total payment amount for this 835 cannot exceed eleven characters, including decimals (99999999.99). Although the value can be zero, the 835 cannot be issued for less than zero dollars.
- Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point).
Code indicating whether amount is a credit or debit
- C
- Credit
Use this code to indicate a credit to the provider's account and a debit to the payer's account, initiated by the payer. In the case of an EFT, no additional action is required of the provider. Also use this code when a check is issued for the payment.
Code identifying the method for the movement of payment instructions
- CHK
- Check
Use this code to indicate that a check has been issued for payment.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- BPR16 is the date the originating company intends for the transaction to be settled (i.e., Payment Effective Date).
- Use this for the effective entry date. If BPR04 is ACH, this is the date that the money moves from the payer and is available to the payee. If BPR04 is CHK, this is the check issuance date. If BPR04 is FWT, this is the date that the payer anticipates the money to move. As long as the effective date is a business day, this is the settlement date. If BPR04 is `NON', enter the date of the 835.
Reassociation Trace Number
To uniquely identify a transaction to an application
- This segment's purpose is to uniquely identify this transaction set and to aid in reassociating payments and remittances that have been separated.
Code identifying which transaction is being referenced
- 1
- Current Transaction Trace Numbers
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
- This number must be unique within the sender/receiver relationship. The number is assigned by the sender. If payment is made by check, this must be the check number. If payment is made by EFT, this must be the EFT reference number. If this is a non-payment 835, this must be a unique remittance advice identification number.
- See 1.10.2.3, Reassociation of Dollars and Data, for additional information.
Check Number
A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.
- TRN03 identifies an organization.
- This must be a 1 followed by the payer's EIN (or TIN).
Receiver Identification
To specify identifying information
- This is the business identification information for the transaction receiver. This may be different than the EDI address or identifier of the receiver. This is the initial receiver of the transaction. This information must not be updated if the transaction is routed through multiple intermediaries, such as clearinghouses, before reaching the payee.
- Required when the receiver of the transaction is other than the payee (e.g., a clearinghouse or billing service). If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
Code qualifying the Reference Identification
- EV
- Receiver Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Receiver Identification Number
Payer Identification
To identify a party by type of organization, name, and code
- Use this N1 loop to provide the name/address information for the payer.
- The payer's secondary identifying reference number is provided in N104, if necessary.
Payer City, State, ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
- Philadelphia
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
- PA
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
- 19107
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Payer Business Contact Information
To identify a person or office to whom administrative communications should be directed
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800) 555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number.
- Required when there is a business contact area that would apply to this remittance and all the claims. If not required by this implementation guide, do not send.
Code identifying the major duty or responsibility of the person or group named
- CX
- Payers Claim Office
Free-form name
- Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1).
- Claim Department
Code identifying the type of communication number
- TE
- Telephone
Complete communications number including country or area code when applicable
- 2159914350
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
When used, the value following this code is the extension for the preceding communications contact number.
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EX
- Telephone Extension
Complete communications number including country or area code when applicable
Payer Technical Contact Information
To identify a person or office to whom administrative communications should be directed
- Required to report technical contact information for this remittance advice.
Code identifying the major duty or responsibility of the person or group named
- BL
- Technical Department
Free-form name
- Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1).
- EDI Support
Code identifying the type of communication number
- TE
- Telephone
Recommended
Complete communications number including country or area code when applicable
- 2159914290
Code identifying the type of communication number
- EM
- Electronic Mail
Complete communications number including country or area code when applicable
- EDI@HEALTHPART.COM
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
When used, the value following this code is theextension for the preceding communicationscontact number.
- FX
- Facsimile
- UR
- Uniform Resource Locator (URL)
Complete communications number including country or area code when applicable
Payer WEB Site
To identify a person or office to whom administrative communications should be directed
- Required when any 2110 loop Healthcare Policy REF Segment is used. If not required by this implementation guide, do not send.
- This is a direct link to the policy location of the un-secure website.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- UR
- Uniform Resource Locator (URL)
Complete communications number including country or area code when applicable
- This is the payer's WEB site URL where providers can find policy and other related information.
- www.healthpart.com
Payee Identification
To identify a party by type of organization, name, and code
- Use this N1 loop to provide the name/address information of the payee. The identifying reference number is provided in N104.
Code identifying an organizational entity, a physical location, property or an individual
- PE
- Payee
Code designating the system/method of code structure used for Identification Code (67)
- FI
- Federal Taxpayer's Identification Number
Required if provider is not mandated by NPI. For individual providers as payees, use this qualifier to represent the Social Security Number.
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
This is REQUIRED when the National Provider Identifier is mandated for use and the payee is a covered health care provider under the mandate.
Code identifying a party or other code
- This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party.
Payee Address
To specify the location of the named party
- Required when the sender needs to communicate the payee address to a transaction receiver, e.g., a VAN or a clearinghouse. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
Situational (when needed to inform Receiver of Payee Address)
Payee City, State, ZIP Code
To specify the geographic place of the named party
- Required when the sender needs to communicate the payee address to a transaction receiver, e.g., a VAN or a clearinghouse. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
Situational (when needed to inform Receiver)
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Payee City Name provided
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Payee State Name provided
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Payee Zip Code provided
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Payee Additional Identification
To specify identifying information
- Required when identification of the payee is dependent upon an identification number beyond that supplied in the N1 segment. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
Situational (When additional identification is needed)
Code qualifying the Reference Identification
- PQ
- Payee Identification
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Health Partners Legacy Number
Payee Additional Identification
To specify identifying information
- Required when identification of the payee is dependent upon an identification number beyond that supplied in the N1 segment. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
Situational (When additional identification is needed)
Code qualifying the Reference Identification
- TJ
- Federal Taxpayer's Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Federal Taxpayer Identification Number
Remittance Delivery Method
To identify remittance delivery when remittance is separate from payment
- Required when BPR01 = U or X; and the remittance is to be sent separately from the payment. The payer is responsible to provide the bank with the instructions on how to deliver the remittance information, if not required by this implementation guide, do not send.
- Payer should coordinate this process with their Originating Depository Financial Institution (ODFI).
Code defining timing, transmission method or format by which reports are to be sent
- BM
- By Mail
When used, RDM02 must be used.
When BM is used, the remittance information will be mailed to the payee at the address identified in this 1000B loop.
- EM
- E-Mail
Use with encrypted e-mail.
- FT
- File Transfer
Use with FTP communications.
- OL
- On-Line
Use with secured hosted or other electronic delivery.
Free-form name
- RDM02 is used to contain the name of a third party processor if needed, who would be the first recipient of the remittance.
- When BM is used, the remittance information will be mailed to the attention of this person at the payee's address identified in this 1000B loop.
Complete communications number including country or area code when applicable
- RDM03 contains the operative communication number for the delivery method specified in RDM01 (i.e. fax phone number and mail address).
- Contains URL web address or e-mail address.
Detail
Header Number
To reference a line number in a transaction set
- Required when claim/service information is being provided in the transaction. If not required by this implementation guide, do not send.
- The purpose of LX01 is to provide an identification of a particular grouping of claims for sorting purposes.
- In the event that claim/service information must be sorted, the LX segment must precede each series of claim level and service level segments. This number is intended to be unique within each transaction.
Number assigned for differentiation within a transaction set
Claim Payment Information
To supply information common to all services of a claim
- For CLP segment occurrence limitations, see section 1.3.2, Other Usage Limitations.
Identifier used to track a claim from creation by the health care provider through payment
- Use this number for the patient control number assigned by the provider. If the patient control number is not present on the incoming claim, enter a single zero. The value in CLP01 must be identical to any value received as a Claim Submitter's Identifier on the original claim (CLM01 of the ANSI ASC X12 837, if applicable). This data element is the primary key for posting the remittance information into the provider's database. In the case of pharmacy claims, this is the prescription reference number (field 402-02 in the NCPDP 5.1 format).
Code identifying the status of an entire claim as assigned by the payor, claim review organization or repricing organization
- To determine the full claim status reference Claim adjustment reason codes in the CAS segment in conjunction with this claim status code.
Claim Status. See page 124 of HIPAA TR3 for valid codes
- 1
- Processed as Primary
Use this code if the claim was adjudicated by the current payer as primary regardless of whether any part of the claim was paid.
- 2
- Processed as Secondary
Use this code if the claim was adjudicated by the current payer as secondary regardless of whether any part of the claim was paid.
- 3
- Processed as Tertiary
Use this code if the claim was adjudicated by the current payer as tertiary (or subsequent) regardless of whether any part of the claim was paid.
- 4
- Denied
Usage of this code would apply if the Patient/Subscriber is not recognized, and the claim was not forwarded to another payer.
- 19
- Processed as Primary, Forwarded to Additional Payer(s)
When this code is used, the Crossover Carrier Name NM1 segment is required.
- 20
- Processed as Secondary, Forwarded to Additional Payer(s)
When this code is used, the Crossover Carrier Name NM1 segment is required.
- 21
- Processed as Tertiary, Forwarded to Additional Payer(s)
When this code is used, the Crossover Carrier Name NM1 segment is required.
- 22
- Reversal of Previous Payment
See section 1.10.2.8 for usage information.
- 23
- Not Our Claim, Forwarded to Additional Payer(s)
Usage of this code would apply if the patient/subscriber is not recognized, the claim was not adjudicated by the payer, but other payers are known and the claim has been forwarded to another payer. When this code is used, the Crossover Carrier Name NM1 segment is required.
- 25
- Predetermination Pricing Only - No Payment
Monetary amount
- CLP03 is the amount of submitted charges this claim.
- See 1.10.2.1, Balancing, in this implementation guide for additional information.
- Use this monetary amount for the submitted charges for this claim. The amount can be positive, zero or negative. An example of a situation with a negative charge is a reversal claim. See section 1.10.2.8 for additional information.
- Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements.
Monetary amount
- CLP04 is the amount paid this claim.
- See 1.10.2.1, Balancing, in this implementation guide for additional information. See section 1.10.2.9 for information about interest considerations.
- Use this monetary amount for the amount paid for this claim. It can be positive, zero or negative, but the value in BPR02 may not be negative.
Monetary amount
- CLP05 is the patient responsibility amount.
- Amounts in CLP05 must have supporting adjustments reflected in CAS segments at the 2100 (CLP) or 2110 (SVC) loop level with a Claim Adjustment Group (CAS01) code of PR (Patient Responsibility).
- Use this monetary amount for the payer's statement of the patient responsibility amount for this claim, which can include such items as deductible, non-covered services, co-pay and co-insurance. This is not used for reversals. See section 1.10.2.8, Reversals and Corrections, for additional information.
Code identifying type of claim
- For many providers to electronically post the 835 remittance data to their patient accounting systems without human intervention, a unique, provider-specific insurance plan code is needed. This code allows the provider to separately identify and manage the different product lines or contractual arrangements between the payer and the provider. Because most payers maintain the same Originating Company Identifier in the TRN03 or BPR10 for all product lines or contractual relationships, the CLP06 is used by the provider as a table pointer in combination with the TRN03 or BPR10 to identify the unique, provider-specific insurance plan code needed to post the payment without human intervention. The value should mirror the value received in the original claim (2-005 SBR09 of the 837), if applicable, or provide the value as assigned or edited by the payer. For example the BL from the SBR09 in the 837 would be returned as 12, 13, 15, in the 835 when more details are known. The 837 SBR09 code CI (Commercial Insurance) is generic, if through adjudication the specific type of plan is obtained a more specific code must be returned in the 835.
- The 837 and 835 transaction code lists for this element are not identical by design. There are some business differences between the two transactions. When a code from the 837 is not available in the 835 another valid code from the 835 must be assigned by the payer.
- HM
- Health Maintenance Organization
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- CLP07 is the payer's internal control number.
- Use this number for the payer's internal control number. This number must apply to the entire claim.
Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.
- Since professional or dental claims can have different place of service codes for services within a single claim, default to the place of service of the first service line when the service lines are not all for the same place of service.
- This number was received in CLM05-1 of the 837 claim.
Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type
- This number was received in CLM05-3 of the 837 Claim.
Code indicating a patient's diagnosis group based on a patient's illness, diseases, and medical problems
Code Source 229. Institutional claims only.
Numeric value of quantity
- CLP12 is the diagnosis-related group (DRG) weight.
- This is the adjudicated DRG Weight.
Claim Adjustment
To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid
- Payers must use this CAS segment to report claim level adjustments that cause the amount paid to differ from the amount originally charged. See 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information.
- See the SVC TR3 Note #1 for details about per diem adjustments.
- A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment must be the first non-zero adjustment and is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
- Required when dollar amounts and/or quantities are being adjusted at the claim level. If not required by this implementation guide, do not send.
Code identifying the general category of payment adjustment
- Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.)
- CO
- Contractual Obligations
Use this code when a joint payer/payee contractual agreement or a regulatory requirement resulted in an adjustment.
- OA
- Other adjustments
Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13.
- PI
- Payor Initiated Reductions
Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments).
- PR
- Patient Responsibility
Code identifying the detailed reason the adjustment was made
- Required to report a non-zero adjustment applied at the claim level for the claim adjustment group code reported in CAS01.
Code Source 139: Claim Adjustment Reason Code
Monetary amount
- CAS03 is the amount of adjustment.
- Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in CLP04.
- Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements.
Claim Level Adjustment Amount
Numeric value of quantity
- CAS04 is the units of service being adjusted.
- See section 1.10.2.4.1 for additional information.
- A positive value decreases the covered days, and a negative number increases the covered days.
Provided only when unit quantity is being adjusted
Patient Name
To supply the full name of an individual or organizational entity
- Provide the patient's identification number in NM109.
- This segment must provide the information from the original claim. For example, when the claim is submitted as an ASC X12 837 transaction, this is the 2010CA loop NM1 Patient Name Segment unless not present on the original claim, then it is the 2010BA loop NM1 Subscriber name segment.
- The Corrected Patient/Insured Name NM1 segment identifies the adjudicated Insured Name and ID information if different than what was submitted on the claim.
Code identifying an organizational entity, a physical location, property or an individual
- QC
- Patient
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual middle name or initial
- If this data element is used and contains only one character, it is assumed to represent the middle initial.
Code designating the system/method of code structure used for Identification Code (67)
- MI
- Member Identification Number
Service Provider Name
To supply the full name of an individual or organizational entity
- This segment provides information about the rendering provider. An identification number is provided in NM109.
- This information is provided to facilitate identification of the claim within a payee's system. Other providers (e.g., Referring provider, supervising provider) related to the claim but not directly related to the payment are not supported and are not necessary for claim identification.
- Required when the rendering provider is different from the payee. If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- 82
- Rendering Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Required value if the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate. Otherwise, one of the other listed codes may be used.
Code identifying a party or other code
National Provider Identifier Number Provided
Other Subscriber Name
To supply the full name of an individual or organizational entity
- This is the name and ID number of the other subscriber when a corrected priority payer has been identified. When used, either the name or ID must be supplied.
- Required when a corrected priority payer has been identified in another NM1 segment AND the name or ID of the other subscriber is known. If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- GB
- Other Insured
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
- At least one of NM103 or NM109 must be present.
Individual middle name or initial
- When only one character is present this is assumed to be the middle initial.
Code designating the system/method of code structure used for Identification Code (67)
- FI
- Federal Taxpayer's Identification Number
Not Used when NM102=1.
- II
- Standard Unique Health Identifier for each Individual in the United States
Use this code if mandated in a final Federal Rule.
- MI
- Member Identification Number
Use this code when supplying the number used for identification of the subscriber in NM109.
Code identifying a party or other code
- At least one of NM103 or NM109 must be present.
Coverage Expiration Date
To specify pertinent dates and times
- Required when payment is denied because of the expiration of coverage. If not required by this implementation guide, do not send.
Situational (Required due to expiration of coverage)
Code specifying type of date or time, or both date and time
- 036
- Expiration
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- This is the expiration date of the patient's coverage.
Claim Received Date
To specify pertinent dates and times
- Required whenever state or federal regulations or the provider contract mandate interest payment or prompt payment discounts based upon the receipt date of the claim by the payer. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
Code specifying type of date or time, or both date and time
- 050
- Received
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- This is the date that the claim was received by the payer.
Claim Supplemental Information
To indicate the total monetary amount
- Use this segment to convey information only. It is not part of the financial balancing of the 835.
- Send/receive one AMT for each applicable non-zero value. Do not report any zero values.
- Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send.
Code to qualify amount
- D8
- Discount Amount
Prompt Pay Discount Amount
See section 1.10.2.9 for additional information.
- I
- Interest
See section 1.10.2.9 for additional information.
- T
- Tax
Monetary amount
- Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements.
Service Payment Information
To supply payment and control information to a provider for a particular service
- See section 1.10.2.1.1 (Service Line Balancing) for additional information.
- The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO78*25~). See section 1.10.2.4.1 for additional information.
- See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information.
- Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7.
See HIPAA 835 Technical Report Type 3, pg. 187-188 for supported codes
- AD
- American Dental Association Codes
- ER
- Jurisdiction Specific Procedure and Supply Codes
- HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC.
- HP
- Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System.
- IV
- Home Infusion EDI Coalition (HIEC) Product/Service Code
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property & Casualty claims/encounters that are not covered under HIPAA.
- N4
- National Drug Code in 5-4-2 Format
- N6
- National Health Related Item Code in 4-6 Format
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names National Health Related Item Code in 4-6 Format Codes as an allowable code set under HIPAA. 2) For Property & Casualty claims/encounters that are not covered under HIPAA.
- NU
- National Uniform Billing Committee (NUBC) UB92 Codes
- UI
- U.P.C. Consumer Package Code (1-5-5)
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names U.P.C. Consumer Package Code (1-5-5) Codes as an allowable code set under HIPAA. 2) For Property & Casualty claims/encounters that are not covered under HIPAA.
- WK
- Advanced Billing Concepts (ABC) Codes
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used in transactions covered under HIPAA by parties registered in the pilot project and their trading partners.
Identifying number for a product or service
- If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
- This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-03 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-04 modifies the value in C003-02 and C003-08.
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.
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.
Monetary amount
- SVC02 is the submitted service charge.
- Use this monetary amount for the submitted service charge amount.
- Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements.
Monetary amount
- SVC03 is the amount paid this service.
- Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. See 1.10.2.1, Balancing, for additional information.
Numeric value of quantity
- SVC05 is the paid units of service.
- If not present, the value is assumed to be one.
Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7.
Provided if procedure code in SVC01 is different from procedure code submitted; see pg. 191 of the HIPAA Technical Report Type 3
- AD
- American Dental Association Codes
- ER
- Jurisdiction Specific Procedure and Supply Codes
- HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC.
- HP
- Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System.
- IV
- Home Infusion EDI Coalition (HIEC) Product/Service Code
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property & Casualty claims/encounters that are not covered under HIPAA.
- N4
- National Drug Code in 5-4-2 Format
- NU
- National Uniform Billing Committee (NUBC) UB92 Codes
- WK
- Advanced Billing Concepts (ABC) Codes
This qualifier can only be used in transactions covere under HIPAA by parties registered in the pilot project and their trading partners.
Identifying number for a product or service
- If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
Numeric value of quantity
- SVC07 is the original submitted units of service.
Only provided when paid unit is different from submitted units
Service Date
To specify pertinent dates and times
- 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.
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.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
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
- An example of this level of CAS is the reduction for the part of the service charge that exceeds the usual and customary charge for the service. See sections 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information.
- Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02). If not required by this implementation guide, do not send.
- A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
Situational (to account for difference in amount paid for this service)
Code identifying the general category of payment adjustment
- Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.)
- CO
- Contractual Obligations
Use this code when a joint payer/payee agreement or a regulatory requirement has resulted in an adjustment.
- OA
- Other adjustments
Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13.
- PI
- Payor Initiated Reductions
Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments).
- PR
- Patient Responsibility
Code identifying the detailed reason the adjustment was made
- Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01.
Code Source 139: Claim Adjustment Reason Code
Monetary amount
- CAS03 is the amount of adjustment.
- 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.
Numeric value of quantity
- CAS04 is the units of service being adjusted.
- A positive number decreases paid units, and a negative value increases paid units.
Service Identification
To specify identifying information
- 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.
Code qualifying the Reference Identification
- 1S
- Ambulatory Patient Group (APG) Number
- APC
- Ambulatory Payment Classification
- BB
- Authorization Number
- E9
- Attachment Code
- G1
- Prior Authorization Number
- G3
- Predetermination of Benefits Identification Number
- LU
- Location Number
This is the Payer's identification for the provider location. This is REQUIRED when the specific site of service affected the payment of the claim.
- RB
- Rate code number
Rate Code Number reflects Ambulatory Surgical Center (ASC) rate for Medicare, either 0, 50, 100 or 150%.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Line Item Control Number
To specify identifying information
- 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.
Rendering Provider Information
To specify identifying information
- 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.
Code qualifying the Reference Identification
- HPI
- Centers for Medicare and Medicaid Services National Provider Identifier
This qualifier is REQUIRED when the National Provider Identifier is mandated for use and the provider is a covered health care provider under that mandate.
- TJ
- Federal Taxpayer's Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Service Supplemental Amount
To indicate the total monetary amount
- 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.
Code to qualify amount
- B6
- Allowed - Actual
Allowed amount is the amount the payer deems payable prior to considering patient responsibility.
- KH
- Deduction Amount
Late Filing Reduction
- T
- Tax
- T2
- Total Claim Before Taxes
Use this monetary amount for the service charge before taxes. This is only used when there is an applicable tax amount on this service.
- ZK
- Federal Medicare or Medicaid Payment Mandate - Category 1
- ZL
- Federal Medicare or Medicaid Payment Mandate - Category 2
- ZM
- Federal Medicare or Medicaid Payment Mandate - Category 3
- ZN
- Federal Medicare or Medicaid Payment Mandate - Category 4
- ZO
- Federal Medicare or Medicaid Payment Mandate - Category 5
Monetary amount
- Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements.
Corresponding Amount (Service Line Allowed Amount)
Health Care Remark Codes
To identify standard industry codes
- 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.
Summary
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
- 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.
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.
- 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.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- PLB02 is the last day of the provider's fiscal year.
- 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.
Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment
Refer to HIPAA Technical Report Type pg. 219-222 for supported Code Values
- 50
- Late Charge
This is the Late Claim Filing Penalty or Medicare Late Cost Report Penalty.
- 51
- Interest Penalty Charge
This is the interest assessment for late filing.
- 72
- Authorized Return
This is the provider refund adjustment. This adjustment acknowledges a refund received from a provider for previous overpayment. PLB03-2 must always contain an identifying reference number when the value is used. PLB04 must contain a negative value. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset.
- 90
- Early Payment Allowance
- AH
- Origination Fee
This is the claim transmission fee. This is used for transmission fees that are not specific to or dependent upon individual claims.
- AM
- Applied to Borrower's Account
See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. Use this code to identify the loan repayment amount.
This is capitation specific.
- AP
- Acceleration of Benefits
This is the accelerated payment amount or withholding. Withholding or payment identification is indicated by the sign of the amount in PLB04. A positive value represents a withholding. A negative value represents a payment.
- B2
- Rebate
This adjustment code applies when a provider has remitted an overpayment to a health plan in excess of the amount requested by the health plan. The amount accepted by the health plan is reported using code 72 (Authorized Return) and offset by the amount with code WO (Overpayment Recovery). The excess returned by the provider is reported as a negative amount using code B2, returning the excess funds to the provider.
- B3
- Recovery Allowance
This represents the check received from the provider for overpayments generated by payments from other payers. This code differs from the provider refund adjustment identified with code 72. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset.
- BD
- Bad Debt Adjustment
This is the bad debt passthrough.
- BN
- Bonus
This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information.
- C5
- Temporary Allowance
This is the tentative adjustment.
- CR
- Capitation Interest
This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information.
- CS
- Adjustment
Provide supporting identification information in PLB03-2.
- CT
- Capitation Payment
This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information.
- CV
- Capital Passthru
- CW
- Certified Registered Nurse Anesthetist Passthru
- DM
- Direct Medical Education Passthru
- E3
- Withholding
See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information.
- FB
- Forwarding Balance
This is the balance forward. A negative value in PLB04 represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice. A reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information.
- FC
- Fund Allocation
This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. The specific fund must be identified in PLB03-2.
- GO
- Graduate Medical Education Passthru
- HM
- Hemophilia Clotting Factor Supplement
- IP
- Incentive Premium Payment
This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information.
- IR
- Internal Revenue Service Withholding
- IS
- Interim Settlement
This is the interim rate lump sum adjustment.
- J1
- Nonreimbursable
This offsets the claim or service level data that reflects what could be paid if not for demonstration program or other limitation that prevents issuance of payment.
- L3
- Penalty
This is the capitation-related penalty. Withholding or release is identified by the sign in PLB04. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information.
- L6
- Interest Owed
This is the interest paid on claims in this 835. Support the amounts related to this adjustment by 2-062 AMT amounts, where AMT01 is "I".
- 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
- 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).
Monetary amount
- PLB04 is the adjustment amount.
- This is the adjustment amount for the preceding adjustment reason.
- Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements.
Transaction Set Trailer
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)
Total number of segments included in a transaction set including ST and SE segments
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- The Transaction Set Control Numbers in ST02 and SE02 must be identical. The originator assigns the Transaction Set Control Number, which must be unique within a functional group (GS-GE). This unique number also aids in error resolution research.
Functional Group Trailer
To indicate the end of a functional group and to provide control information
Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element
Assigned number originated and maintained by the sender
Interchange Control Trailer
To define the end of an interchange of zero or more functional groups and interchange-related control segments
Example 1: Dollars and Data Sent Separately
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*112233~
BPR*I*1100*C*ACH*CCP*01*888999777*DA*24681012*1935665544**01*111333555*DA*144444*20190316~
TRN*1*71700666555*1935665544~
DTM*405*20190314~
N1*PR*RUSHMORE LIFE~
N3*10 SOUTH AVENUET~
N4*RAPID CITY*SD*55111~
PER*BL*JOHN WAYNE*TE*8005551212*EX*123~
N1*PE*ACME MEDICAL CENTER*XX*5544667733~
REF*TJ*777667755~
LX*1~
CLP*5554555444*1*800*500*300*12*94060555410000*11*1~
NM1*QC*1*BUDD*WILLIAM****MI*33344555510~
AMT*AU*800~
SVC*HC>99211*800*500~
DTM*472*20190301~
CAS*PR*1*300~
AMT*B6*800~
CLP*8765432112*1*1200*600*600*12*9407779923000*11*1~
NM1*QC*1*SETTLE*SUSAN****MI*44455666610~
AMT*AU*1200~
SVC*HC>93555*1200*600~
DTM*472*20190310~
CAS*PR*1*600~
AMT*B6*1200~
SE*26*112233~
GE*1*12345678~
IEA*1*191511902~
Example 2: Multiple Claims Single Check
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*35681~
BPR*I*810.8*C*CHK************20190331~
TRN*1*12345*1512345678~
REF*EV*XYZ CLEARINGHOUSE~
N1*PR*DENTAL OF ABC~
N3*225 MAIN STREET~
N4*CENTERVILLE*PA*17111~
PER*BL*JANE DOE*TE*9005555555~
N1*PE*BAN DDS LLC*XX*9999947036~
REF*TJ*212121212~
LX*1~
CLP*7722337*1*226*132**12*119932404007801*11*1~
NM1*QC*1*DOE*SANDY****MI*SJD11112~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*132~
SVC*AD>D0120*46*25~
DTM*472*20190324~
CAS*CO*45*21~
AMT*B6*25~
SVC*AD>D0220*25*14~
DTM*472*20190324~
CAS*CO*45*11~
AMT*B6*14~
SVC*AD>D0230*22*10~
DTM*472*20190324~
CAS*CO*45*12~
AMT*B6*10~
SVC*AD>D0274*60*34~
DTM*472*20190324~
CAS*CO*45*26~
AMT*B6*34~
SVC*AD>D1110*73*49~
DTM*472*20190324~
CAS*CO*45*24~
AMT*B6*49~
CLP*7722337*1*119*74**12*119932404007801*11*1~
NM1*QC*1*DOE*SALLY****MI*SJD11111~
NM1*IL*1*DOE*JOHN****MI*SJD11111~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*74~
SVC*AD>D0120*46*25~
DTM*472*20190324~
CAS*CO*45*21~
AMT*B6*25~
SVC*AD>D1110*73*49~
DTM*472*20190324~
CAS*CO*45*24~
AMT*B6*49~
CLP*7722337*1*226*108*24*12*119932404007801*11*1~
NM1*QC*1*SMITH*SALLY****MI*SJD11113~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*132~
SVC*AD>D0120*46*25~
DTM*472*20190324~
CAS*CO*45*21~
AMT*B6*25~
SVC*AD>D0220*25*0~
DTM*472*20190324~
CAS*PR*3*14~
CAS*CO*45*11~
AMT*B6*14~
SVC*AD>D0230*22*0~
DTM*472*20190324~
CAS*PR*3*10~
CAS*CO*45*12~
AMT*B6*10~
SVC*AD>D0274*60*34~
DTM*472*20190324~
CAS*CO*45*26~
AMT*B6*34~
SVC*AD>D1110*73*49~
DTM*472*20190324~
CAS*CO*45*24~
AMT*B6*49~
CLP*7722337*1*1145*14*902*12*119932404007801*11*1~
NM1*QC*1*SMITH*SAM****MI*SJD11116~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*14~
SVC*AD>D0220*25*14~
DTM*472*20190324~
CAS*CO*45*11~
AMT*B6*14~
SVC*AD>D2790*940*0~
DTM*472*20190324~
CAS*PR*3*756~
CAS*CO*45*184~
SVC*AD>D2950*180*0~
DTM*472*20190324~
CAS*PR*3*146~
CAS*CO*45*34~
CLP*7722337*1*348*16.8*44.2*12*119932404007801*11*1~
NM1*QC*1*JONES*SAM****MI*SJD11122~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*28~
SVC*AD>D4342*125*0~
DTM*472*20190313~
CAS*CO*45*125~
SVC*AD>D4381*43*0~
DTM*472*20190313~
CAS*PR*3*33~
CAS*CO*45*10~
SVC*AD>D2950*180*16.8~
DTM*472*20190313~
CAS*PR*3*11.2~
CAS*CO*45*152~
AMT*B6*28~
CLP*7722337*1*226*132**12*119932404007801*11*1~
NM1*QC*1*JONES*SALLY****MI*SJD11133~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*132~
SVC*AD>D0120*46*25~
DTM*472*20190321~
CAS*CO*45*21~
AMT*B6*25~
SVC*AD>D0220*25*14~
DTM*472*20190321~
CAS*CO*45*11~
AMT*B6*14~
SVC*AD>D0230*22*10~
DTM*472*20190321~
CAS*CO*45*12~
AMT*B6*10~
SVC*AD>D0274*60*34~
DTM*472*20190321~
CAS*CO*45*26~
AMT*B6*34~
SVC*AD>D1110*73*49~
DTM*472*20190321~
CAS*CO*45*24~
AMT*B6*49~
CLP*7722337*1*179*108**12*119932404007801*11*1~
NM1*QC*1*DOE*SAM****MI*SJD99999~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*108~
SVC*AD>D0120*46*25~
DTM*472*20190324~
CAS*CO*45*21~
AMT*B6*25~
SVC*AD>D0274*60*34~
DTM*472*20190324~
CAS*CO*45*26~
AMT*B6*34~
SVC*AD>D1110*73*49~
DTM*472*20190324~
CAS*CO*45*24~
AMT*B6*49~
CLP*7722337*1*129*82**12*119932404007801*11*1~
NM1*QC*1*DOE*SUE****MI*SJD88888~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*82~
SVC*AD>D0120*46*25~
DTM*472*20190324~
CAS*CO*45*21~
AMT*B6*25~
SVC*AD>D1120*54*37~
DTM*472*20190324~
CAS*CO*45*17~
AMT*B6*37~
SVC*AD>D1208*29*20~
DTM*472*20190324~
CAS*CO*45*9~
AMT*B6*20~
CLP*7722337*1*221*144**12*119932404007801*11*1~
NM1*QC*1*DOE*DONNA****MI*SJD77777~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*144~
SVC*AD>D0120*46*25~
DTM*472*20190324~
CAS*CO*45*21~
AMT*B6*25~
SVC*AD>D0330*92*62~
DTM*472*20190324~
CAS*CO*45*30~
AMT*B6*62~
SVC*AD>D1120*54*37~
DTM*472*20190324~
CAS*CO*45*17~
AMT*B6*37~
SVC*AD>D1208*29*20~
DTM*472*20190324~
CAS*CO*45*9~
AMT*B6*20~
SE*182*35681~
GE*1*12345678~
IEA*1*191511902~
Example 3: Claim Specific Negotiated Discount
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*35681~
BPR*I*132*C*CHK************20190331~
TRN*1*12345*1512345678~
REF*EV*CLEARINGHOUSE~
N1*PR*DELTA DENTAL OF ABC~
N3*225 MAIN STREET~
N4*CENTERVILLE*PA*17111~
PER*BL*JANE DOE*TE*9005555555~
N1*PE*BAN DDS LLC*FI*999994703~
LX*1~
CLP*7722337*1*226*132**12*119932404007801~
NM1*QC*1*DOE*SALLY****MI*SJD11111~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*132~
SVC*AD>D0120*46*25~
DTM*472*20190324~
CAS*CO*131*21~
AMT*B6*25~
SVC*AD>D0220*25*14~
DTM*472*20190324~
CAS*CO*131*11~
AMT*B6*14~
SVC*AD>D0230*22*10~
DTM*472*20190324~
CAS*CO*131*12~
AMT*B6*10~
SVC*AD>D0274*60*34~
DTM*472*20190324~
CAS*CO*131*26~
AMT*B6*34~
SVC*AD>D1110*73*49~
DTM*472*20190324~
CAS*CO*131*24~
AMT*B6*49~
SE*34*35681~
GE*1*12345678~
IEA*1*191511902~
Example 4: Claim Adjustment Reason Code 45
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*10060875~
BPR*I*80.00*C*CHK************20190816~
TRN*1*CK NUMBER 1*1234567890~
REF*EV*FAC~
DTM*405*20190827~
N1*PR*ANY PLAN USA~
N3*1 WALK THIS WAY~
N4*ANYCITY*OH*45209~
PER*CX**TE*8661112222~
PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
PER*IC**UR*WWW.ANYPAYER.COM~
N1*PE*PROVIDER*XX*1123454567~
N3*2255 ANY ROAD~
N4*ANY CITY*CA*12211~
REF*TJ*123456789~
LX*1~
CLP*PATACCT*1*400*80**MC*CLAIMNUMBER*11*1~
NM1*QC*1*DOE*JOHN*N***MI*ABC123456789~
REF*1L*12345F~
DTM*050*20190209~
PER*CX*G CUSTOMER SERVICE DEPARTMENT*TE*8004074627~
AMT*AU*150~
SVC*HC>99213*150*80**1~
DTM*472*20190101~
CAS*CO*45*70~
AMT*B6*80~
SVC*HC>85003*100*0**1~
DTM*472*20190101~
CAS*CO*204*100~
SVC*HC>36415*150*0**1~
DTM*472*20190101~
CAS*CO*97*150~
SE*33*10060875~
GE*1*12345678~
IEA*1*191511902~
Example 5a: Line Service Tax impacting payment only
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*10060875~
BPR*I*11.06*C*CHK************20190816~
TRN*1*CK NUMBER 1*1234567890~
REF*EV*FAC~
DTM*405*20190827~
N1*PR*ANY PLAN USA~
N3*1 WALK THIS WAY~
N4*ANYCITY*OH*45209~
PER*CX**TE*8661112222~
PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
PER*IC**UR*WWW.ANYPAYER.COM~
N1*PE*PROVIDER*XX*1123454567~
N3*2255 ANY ROAD~
N4*ANY CITY*CA*12211~
REF*TJ*123456789~
LX*1~
CLP*PCN*1*36.20*11.06**12*CLAIMNUMB*11*1~
NM1*QC*1*LAST*FIRST*J***MI*123456789~
NM1*82*1******XX*1447481825~
MOA***N25~
REF*1L*102345~
REF*EA*065789~
DTM*050*20170113~
AMT*AU*36.20~
SVC*HC>99214*26.2*3.06~
DTM*472*20170109~
CAS*CO*45*23.2**137*-.06~
REF*6R*B1~
AMT*B6*3~
SVC*HC>36415*10*8~
DTM*472*20170109~
CAS*CO*45*2~
REF*6R*B2~
AMT*B6*8~
SE*35*10060875~
GE*1*12345678~
IEA*1*191511902~
Example 5b: Line Service Bonuses impacting payment only
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*10060875~
BPR*I*12.00*C*CHK************20190816~
TRN*1*CK NUMBER 1*1234567890~
REF*EV*FAC~
DTM*405*20190827~
N1*PR*ANY PLAN USA~
N3*1 WALK THIS WAY~
N4*ANYCITY*OH*45209~
PER*CX**TE*8661112222~
PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
PER*IC**UR*WWW.ANYPAYER.COM~
N1*PE*PROVIDER*XX*1123454567~
N3*2255 ANY ROAD~
N4*ANY CITY*CA*12211~
REF*TJ*123456789~
LX*1~
CLP*PCN*1*25*12*10*12*CLAIMNUMB*11*1~
NM1*QC*1*LAST*FIRST*J***MI*123456789~
NM1*82*1******XX*1447481825~
MOA***N25~
REF*1L*102345~
REF*EA*065789~
DTM*050*20170113~
AMT*AU*25~
SVC*HC>99214*25*12~
DTM*472*20170109~
CAS*CO*45*5**161*-2~
CAS*PR*3*10~
REF*6R*123~
AMT*B6*20~
SE*31*10060875~
GE*1*12345678~
IEA*1*191511902~
Example 5c: Line Service Penalty impacting payment only
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*10060875~
BPR*I*8.00*C*CHK************20190816~
TRN*1*CK NUMBER 1*1234567890~
REF*EV*FAC~
DTM*405*20190827~
N1*PR*ANY PLAN USA~
N3*1 WALK THIS WAY~
N4*ANYCITY*OH*45209~
PER*CX**TE*8661112222~
PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
PER*IC**UR*WWW.ANYPAYER.COM~
N1*PE*PROVIDER*XX*1123454567~
N3*2255 ANY ROAD~
N4*ANY CITY*CA*12211~
REF*TJ*123456789~
LX*1~
CLP*PCN*1*25*8*10*12*CLAIMNUMB*11*1~
NM1*QC*1*LAST*FIRST*J***MI*123456789~
NM1*82*1******XX*1447481825~
MOA***N25~
REF*1L*102345~
REF*EA*065789~
DTM*050*20170113~
AMT*AU*25~
SVC*HC>99214*25*8~
DTM*472*20170109~
CAS*CO*45*5**B4*2~
CAS*PR*3*10~
REF*6R*123~
AMT*B6*20~
SE*31*10060875~
GE*1*12345678~
IEA*1*191511902~
Example 6: Not Covered/Not Authorized Inpatient Facility claim days
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*10060875~
BPR*I*8000.00*C*CHK************20190816~
TRN*1*CK NUMBER 1*1234567890~
REF*EV*FAC~
DTM*405*20190827~
N1*PR*ANY PLAN USA~
N3*1 WALK THIS WAY~
N4*ANYCITY*OH*45209~
PER*CX**TE*8661112222~
PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
PER*IC**UR*WWW.ANYPAYER.COM~
N1*PE*PROVIDER*XX*1123454567~
N3*2255 ANY ROAD~
N4*ANY CITY*CA*12211~
REF*TJ*123456789~
LX*1~
CLP*PATACCT*1*40000*8000**MC*CLAIMNUMBER*11*1~
CAS*CO*197*2000*1*45*30000~
NM1*QC*1*DOE*JOHN*N***MI*ABC123456789~
REF*1L*12345F~
DTM*232*20190101~
DTM*233*20190105~
DTM*050*20190209~
PER*CX*G CUSTOMER SERVICE DEPARTMENT*TE*8004001212~
AMT*AU*38000~
QTY*CA*4~
SE*27*10060875~
GE*1*12345678~
IEA*1*191511902~
Example 8a: Claim submitted with incorrect subscriber as patient and incorrect ID
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*10060875~
BPR*I*120.03*C*CHK************20190816~
TRN*1*CK NUMBER 1*1234567890~
REF*EV*FAC~
DTM*405*20190827~
N1*PR*ANY PLAN USA~
N3*1 WALK THIS WAY~
N4*ANYCITY*OH*45209~
PER*CX**TE*8661112222~
PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
PER*IC**UR*WWW.ANYPAYER.COM~
N1*PE*PROVIDER*XX*1123454567~
N3*2255 ANY ROAD~
N4*ANY CITY*CA*12211~
REF*TJ*123456789~
LX*1~
CLP*04777796TLC777122*1*155*120.03**13*8838888212*11*1~
NM1*QC*1*MASTERS*MARVIN*L****MI*80444444403~
NM1*IL*1*CABLE*MABEL****MI*80444444403~
NM1*74*1*MASTERS*MARVIN****C*80444444401~
NM1*82*1*SHELTON MD*BLAKE****XX*1666666666~
REF*1L*28~
REF*CE*HSOAP-LAOA~
REF*TJ*555555555 ~
DTM*232*20191114~
DTM*233*20181114~
DTM*050*20181119~
AMT*AU*155~
SVC*HC|99393*155*120.03**1~
DTM*472*20181114~
CAS*CO*45*34.97~
REF*LU*11~
REF*6R*22261822~
AMT*B6*120.03~
SE*35*10060875~
GE*1*12345678~
IEA*1*191511902~
Example 8b: Claim submitted with incorrect subscriber name and ID
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*10060875~
BPR*I*35.06*C*CHK************20190816~
TRN*1*CK NUMBER 1*1234567890~
REF*EV*FAC~
DTM*405*20190827~
N1*PR*ANY PLAN USA~
N3*1 WALK THIS WAY~
N4*ANYCITY*OH*45209~
PER*CX**TE*8661112222~
PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
PER*IC**UR*WWW.ANYPAYER.COM~
N1*PE*PROVIDER*XX*1123454567~
N3*2255 ANY ROAD~
N4*ANY CITY*CA*12211~
REF*TJ*123456789~
LX*1~
CLP*02333TLC222222*1*115*35.06*35*13*8333333214*11*1~
NM1*QC*1*KEATON*ALEX*P****MI*80000006006~
NM1*IL*1*THOMAS*JASON****MI*80000006006~
NM1*74*1**JEROME****C*80000006001~
NM1*82*1*BLOOD MD*RED N****XX*1888888886~
REF*1L*28~
REF*CE*OAPOS-LAOA~
DTM*232*20191113~
DTM*233*20191113~
DTM*050*20191119~
AMT*AU*115~
SVC*HC|99213*115*35.06**1~
DTM*472*20191113~
CAS*CO*45*44.94~
CAS*PR*3*35~
REF*LU*11~
REF*6R*22261389~
AMT*B6*70.06~
SE*35*10060875~
GE*1*12345678~
IEA*1*191511902~
Example 8c: Claim submitted with for subscriber missing the Middle initial
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*10060875~
BPR*I*2415.25*C*CHK************20190816~
TRN*1*CK NUMBER 1*1234567890~
REF*EV*FAC~
DTM*405*20190827~
N1*PR*ANY PLAN USA~
N3*1 WALK THIS WAY~
N4*ANYCITY*OH*45209~
PER*CX**TE*8661112222~
PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
PER*IC**UR*WWW.ANYPAYER.COM~
N1*PE*PROVIDER*XX*1123454567~
N3*2255 ANY ROAD~
N4*ANY CITY*CA*12211~
REF*TJ*123456789~
LX*1~
CLP*05444444TLC999999*1*3903*2415.25**13*8777777782*21*1~
NM1*QC*1*GONZALES*SAMMY****MI*80455555502~
NM1*IL*1*LAPLANTE*FERN****MI*80455555502~
NM1*74*1***R~
NM1*82*1*GOOD MD*ROBERT B****XX*19999999987~
REF*1L*28~
REF*CE*OAPOS-LAOA~
DTM*232*20191101~
DTM*233*20191101~
DTM*050*20191114~
AMT*AU*3903~
AMT*F5*150~
SVC*HC>59400*3903*2415.25**1~
DTM*472*20191101~
CAS*CO*45*1487.75~
REF*LU*21~
REF*6R*22215592~
AMT*B6*2415.25~
SE*35*10060875~
GE*1*12345678~
IEA*1*191511902~
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