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Health Care Claim Payment/Advice (X221A1)
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X12 835 Health Care Claim Payment/Advice (X221A1)

X12 Release 5010

This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Payment/Advice Transaction Set (835) for use within the context of the Electronic Data Interchange (EDI) environment.
This transaction set can be used to make a payment, send an Explanation of Benefits (EOB) remittance advice, or make a payment and send an EOB remittance advice only from a health insurer to a health care provider either directly or via a financial institution.

Delimiters
  • ~ Segment
  • * Element
  • > Component
  • ^ Repetition
EDI samples
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    Overview
    ISA
    -
    Interchange Control Header
    Max use 1
    Required
    GS
    -
    Functional Group Header
    Max use 1
    Required
    heading
    ST
    0100
    Transaction Set Header
    Max use 1
    Required
    BPR
    0200
    Financial Information
    Max use 1
    Required
    TRN
    0400
    Reassociation Trace Number
    Max use 1
    Required
    CUR
    0500
    Foreign Currency Information
    Max use 1
    Optional
    REF
    0600
    Receiver Identification
    Max use 1
    Optional
    REF
    0600
    Version Identification
    Max use 1
    Optional
    DTM
    0700
    Production Date
    Max use 1
    Optional
    Payee Identification Loop
    detail
    Header Number Loop
    LX
    0030
    Header Number
    Max use 1
    Required
    TS3
    0050
    Provider Summary Information
    Max use 1
    Optional
    TS2
    0070
    Provider Supplemental Summary Information
    Max use 1
    Optional
    GE
    -
    Functional Group Trailer
    Max use 1
    Required
    IEA
    -
    Interchange Control Trailer
    Max use 1
    Required
    ISA

    Interchange Control Header

    RequiredMax use 1

    To start and identify an interchange of zero or more functional groups and interchange-related control segments

    Example
    ISA-01
    I01
    Authorization Information Qualifier
    Required

    Code identifying the type of information in the Authorization Information

    00
    No Authorization Information Present (No Meaningful Information in I02)
    ISA-02
    I02
    Authorization Information
    Required
    Min 10Max 10

    Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)

    ISA-03
    I03
    Security Information Qualifier
    Required

    Code identifying the type of information in the Security Information

    00
    No Security Information Present (No Meaningful Information in I04)
    ISA-04
    I04
    Security Information
    Required
    Min 10Max 10

    This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)

    ISA-05
    I05
    Interchange ID Qualifier
    Required
    Min 2Max 2

    Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

    Codes
    ISA-06
    I06
    Interchange Sender ID
    Required
    Min 15Max 15

    Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element

    ISA-07
    I05
    Interchange ID Qualifier
    Required
    Min 2Max 2

    Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

    Codes
    ISA-08
    I07
    Interchange Receiver ID
    Required
    Min 15Max 15

    Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them

    ISA-09
    I08
    Interchange Date
    Required
    YYMMDD format

    Date of the interchange

    ISA-10
    I09
    Interchange Time
    Required
    HHMM format

    Time of the interchange

    ISA-11
    I65
    Repetition Separator
    Required
    Min 1Max 1

    Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator

    ^
    Repetition Separator
    ISA-12
    I11
    Interchange Control Version Number
    Required

    Code specifying the version number of the interchange control segments

    00501
    Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
    ISA-13
    I12
    Interchange Control Number
    Required
    Min 9Max 9

    A control number assigned by the interchange sender

    ISA-14
    I13
    Acknowledgment Requested
    Required
    Min 1Max 1

    Code indicating sender's request for an interchange acknowledgment

    0
    No Interchange Acknowledgment Requested
    1
    Interchange Acknowledgment Requested (TA1)
    ISA-15
    I14
    Interchange Usage Indicator
    Required
    Min 1Max 1

    Code indicating whether data enclosed by this interchange envelope is test, production or information

    I
    Information
    P
    Production Data
    T
    Test Data
    ISA-16
    I15
    Component Element Separator
    Required
    Min 1Max 1

    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

    RequiredMax use 1

    To indicate the beginning of a functional group and to provide control information

    Example
    GS-01
    479
    Functional Identifier Code
    Required

    Code identifying a group of application related transaction sets

    HP
    Health Care Claim Payment/Advice (835)
    GS-02
    142
    Application Sender's Code
    Required
    Min 2Max 15

    Code identifying party sending transmission; codes agreed to by trading partners

    GS-03
    124
    Application Receiver's Code
    Required
    Min 2Max 15

    Code identifying party receiving transmission; codes agreed to by trading partners

    GS-04
    373
    Date
    Required
    CCYYMMDD format

    Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

    GS-05
    337
    Time
    Required
    HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

    Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)

    GS-06
    28
    Group Control Number
    Required
    Min 1Max 9

    Assigned number originated and maintained by the sender

    GS-07
    455
    Responsible Agency Code
    Required
    Min 1Max 2

    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
    GS-08
    480
    Version / Release / Industry Identifier Code
    Required

    Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed

    005010X221A1
    ANSI ASC X12.835 Health Care Claim Payment/Advice (835) mandated under HIPAA through June 2010

    Heading

    ST
    0100

    Transaction Set Header

    RequiredMax use 1

    To indicate the start of a transaction set and to assign a control number

    Example
    ST-01
    143
    Transaction Set Identifier Code
    Required

    Code uniquely identifying a Transaction Set

    • The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
    Usage notes
    • The only valid value within this transaction set for ST01 is 835.
    835
    Health Care Claim Payment/Advice
    ST-02
    329
    Transaction Set Control Number
    Required
    Min 4Max 9

    Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

    Usage notes
    • The Transaction Set Control Numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Start with a number, for example 0001, and increment from there. This number must be unique within a specific group and interchange, but it can be repeated in other groups and interchanges.
    BPR
    0200

    Financial Information

    RequiredMax use 1

    To indicate the beginning of a Payment Order/Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and/or information from payer to payee to occur

    Usage notes
    • Use the BPR to address a single payment to a single payee. A payee may represent a single provider, a provider group, or multiple providers in a chain. The BPR contains mandatory information, even when it is not being used to move funds electronically.
    Example
    If either Depository Financial Institution (DFI) Identification Number Qualifier (BPR-06) or Sender DFI Identifier (BPR-07) is present, then the other is required
    If Account Number Qualifier (BPR-08) is present, then Sender Bank Account Number (BPR-09) is required
    If either Depository Financial Institution (DFI) Identification Number Qualifier (BPR-12) or Receiver or Provider Bank ID Number (BPR-13) is present, then the other is required
    If Account Number Qualifier (BPR-14) is present, then Receiver or Provider Account Number (BPR-15) is required
    BPR-01
    305
    Transaction Handling Code
    Required

    Code designating the action to be taken by all parties

    C
    Payment Accompanies Remittance Advice

    Use this code to instruct your third party processor to move both funds and remittance detail together through the banking system.

    D
    Make Payment Only

    Use this code to instruct your third party processor to move only funds through the banking system and to ignore any remittance information.

    H
    Notification Only

    Use this code when the actual provider payment (BPR02) is zero and the transaction is not being used for Prenotification of Future Transfers. This indicates remittance information without any associated payment.

    I
    Remittance Information Only

    Use this code to indicate to the payee that the remittance detail is moving separately from the payment.

    P
    Prenotification of Future Transfers

    This code is used only by the payer and the banking system to initially validate account numbers before beginning an EFT relationship. Contact your VAB for additional information.

    U
    Split Payment and Remittance

    Use this code to instruct the third party processor to split the payment and remittance detail, and send each on a separate path.

    X
    Handling Party's Option to Split Payment and Remittance

    Use this code to instruct the third party processor to move the payment and remittance detail, either together or separately, based upon end point requests or capabilities.

    BPR-02
    782
    Total Actual Provider Payment Amount
    Required
    Min 1Max 15

    Monetary amount

    • BPR02 specifies the payment amount.
    Usage notes
    • Use BPR02 for the total payment amount for this 835. The total payment amount for this 835 cannot exceed eleven characters, including decimals (99999999.99). Although the value can be zero, the 835 cannot be issued for less than zero dollars.
    • Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point).
    BPR-03
    478
    Credit or Debit Flag Code
    Required

    Code indicating whether amount is a credit or debit

    C
    Credit

    Use this code to indicate a credit to the provider's account and a debit to the payer's account, initiated by the payer. In the case of an EFT, no additional action is required of the provider. Also use this code when a check is issued for the payment.

    D
    Debit

    Use this code to indicate a debit to the payer's account and a credit to the provider's account, initiated by the provider at the instruction of the payer. Extreme caution must be used when using Debit transactions. Contact your VAB for information about debit transactions. The rest of this segment and document assumes that a credit payment is being used.

    BPR-04
    591
    Payment Method Code
    Required

    Code identifying the method for the movement of payment instructions

    ACH
    Automated Clearing House (ACH)

    Use this code to move money electronically through the ACH, or to notify the provider that an ACH transfer was requested. When this code is used, see BPR05 through BPR15 for additional requirements.

    BOP
    Financial Institution Option

    Use this code to indicate that the third party processor will choose the method of payment based upon end point requests or capabilities. When this code is used, see BPR05 through BPR15 for additional requirements.

    CHK
    Check

    Use this code to indicate that a check has been issued for payment.

    FWT
    Federal Reserve Funds/Wire Transfer - Nonrepetitive

    Use this code to indicate that the funds were sent through the wire system. When this code is used, see BPR05 through BPR15 for additional requirements.

    NON
    Non-Payment Data

    Use this code when the Transaction Handling Code (BPR01) is H, indicating that this is information only and no dollars are to be moved.

    BPR-05
    812
    Payment Format Code
    Optional

    Code identifying the payment format to be used

    CCP
    Cash Concentration/Disbursement plus Addenda (CCD+) (ACH)

    Use the CCD+ format to move money and up to 80 characters of data, enough to reassociate dollars and data when the dollars are sent through the ACH and the data is sent on a separate path. The addenda must contain a copy of the TRN segment.

    CTX
    Corporate Trade Exchange (CTX) (ACH)

    Use the CTX format to move dollars and data through the ACH. The CTX format can contain up to 9,999 addenda records of 80 characters each. The CTX encapsulates the complete 835 and all envelope segments.

    BPR-06
    506
    Depository Financial Institution (DFI) Identification Number Qualifier
    Optional

    Code identifying the type of identification number of Depository Financial Institution (DFI)

    • When using this transaction set to initiate a payment, all or some of BPR06 through BPR16 may be required, depending on the conventions of the specific financial channel being used.
    • BPR06 and BPR07 relate to the originating depository financial institution (ODFI).
    Usage notes
    • BPR06 through BPR09 relate to the originating financial institution and the originator's account (payer).
    01
    ABA Transit Routing Number Including Check Digits (9 digits)

    The ABA transit routing number is a unique number identifying every bank in the United States.

    04
    Canadian Bank Branch and Institution Number
    BPR-07
    507
    Sender DFI Identifier
    Optional
    Min 3Max 12

    Depository Financial Institution (DFI) identification number

    Usage notes
    • Use this number for the identifying number of the financial institution sending the transaction into the applicable network.
    BPR-08
    569
    Account Number Qualifier
    Optional

    Code indicating the type of account

    • BPR08 is a code identifying the type of bank account or other financial asset.
    Usage notes
    • Use this code to identify the type of account in BPR09.
    DA
    Demand Deposit
    BPR-09
    508
    Sender Bank Account Number
    Optional
    Min 1Max 35

    Account number assigned

    • BPR09 is the account of the company originating the payment. This account may be debited or credited depending on the type of payment order.
    Usage notes
    • Use this number for the originator's account number at the financial institution.
    BPR-10
    509
    Payer Identifier
    Optional
    Min 10Max 10

    A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

    • BPR10 shall be mutually established between the originating depository financial institution (ODFI) and the company originating the payment.
    BPR-11
    510
    Originating Company Supplemental Code
    Optional
    Min 9Max 9

    A code defined between the originating company and the originating depository financial institution (ODFI) that uniquely identifies the company initiating the transfer instructions

    Usage notes
    • Use this code to further identify the payer by division or region. The element must be left justified and space filled to meet the minimum element size requirements. If used, this code must be identical to TRN04, excluding trailing spaces.
    BPR-12
    506
    Depository Financial Institution (DFI) Identification Number Qualifier
    Optional

    Code identifying the type of identification number of Depository Financial Institution (DFI)

    • BPR12 and BPR13 relate to the receiving depository financial institution (RDFI).
    Usage notes
    • BPR12 through BPR15 relate to the receiving financial institution and the receiver's account.
    01
    ABA Transit Routing Number Including Check Digits (9 digits)

    The ABA transit routing number is a unique number identifying every bank in the United States.

    04
    Canadian Bank Branch and Institution Number
    BPR-13
    507
    Receiver or Provider Bank ID Number
    Optional
    Min 3Max 12

    Depository Financial Institution (DFI) identification number

    Usage notes
    • Use this number for the identifying number of the financial institution receiving the transaction from the applicable network.
    BPR-14
    569
    Account Number Qualifier
    Optional

    Code indicating the type of account

    • BPR14 is a code identifying the type of bank account or other financial asset.
    Usage notes
    • Use this code to identify the type of account in BPR15.
    DA
    Demand Deposit
    SG
    Savings
    BPR-15
    508
    Receiver or Provider Account Number
    Optional
    Min 1Max 35

    Account number assigned

    • BPR15 is the account number of the receiving company to be debited or credited with the payment order.
    Usage notes
    • Use this number for the receiver's account number at the financial institution.
    BPR-16
    373
    Check Issue or EFT Effective Date
    Required
    CCYYMMDD format

    Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

    • BPR16 is the date the originating company intends for the transaction to be settled (i.e., Payment Effective Date).
    Usage notes
    • Use this for the effective entry date. If BPR04 is ACH, this is the date that the money moves from the payer and is available to the payee. If BPR04 is CHK, this is the check issuance date. If BPR04 is FWT, this is the date that the payer anticipates the money to move. As long as the effective date is a business day, this is the settlement date. If BPR04 is `NON', enter the date of the 835.
    TRN
    0400

    Reassociation Trace Number

    RequiredMax use 1

    To uniquely identify a transaction to an application

    Usage notes
    • This segment's purpose is to uniquely identify this transaction set and to aid in reassociating payments and remittances that have been separated.
    Example
    TRN-01
    481
    Trace Type Code
    Required

    Code identifying which transaction is being referenced

    1
    Current Transaction Trace Numbers
    TRN-02
    127
    Check or EFT Trace Number
    Required
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    • TRN02 provides unique identification for the transaction.
    Usage notes
    • This number must be unique within the sender/receiver relationship. The number is assigned by the sender. If payment is made by check, this must be the check number. If payment is made by EFT, this must be the EFT reference number. If this is a non-payment 835, this must be a unique remittance advice identification number.
    • See 1.10.2.3, Reassociation of Dollars and Data, for additional information.
    TRN-03
    509
    Payer Identifier
    Required
    Min 10Max 10

    A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

    • TRN03 identifies an organization.
    Usage notes
    • This must be a 1 followed by the payer's EIN (or TIN).
    TRN-04
    127
    Originating Company Supplemental Code
    Optional
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    • TRN04 identifies a further subdivision within the organization.
    Usage notes
    • If both TRN04 and BPR11 are used, they must be identical, excluding trailing spaces. Since BPR11 has a min/max value of 9/9, whenever both are used, this element is restricted to a maximum size of 9.
    CUR
    0500

    Foreign Currency Information

    OptionalMax use 1

    To specify the currency (dollars, pounds, francs, etc.) used in a transaction

    Usage notes
    • When the CUR segment is not present, the currency of payment is defined as US dollars.
    • Required when the payment is not being made in US dollars. If not required by this implementation guide, do not send.
    Example
    CUR-01
    98
    Entity Identifier Code
    Required

    Code identifying an organizational entity, a physical location, property or an individual

    PR
    Payer
    CUR-02
    100
    Currency Code
    Required
    Min 3Max 3

    Code (Standard ISO) for country in whose currency the charges are specified

    Usage notes
    • This is the currency code for the payment currency.
    REF
    0600

    Receiver Identification

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • This is the business identification information for the transaction receiver. This may be different than the EDI address or identifier of the receiver. This is the initial receiver of the transaction. This information must not be updated if the transaction is routed through multiple intermediaries, such as clearinghouses, before reaching the payee.
    • Required when the receiver of the transaction is other than the payee (e.g., a clearinghouse or billing service). If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
    Example
    Variants (all may be used)
    REFVersion Identification
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    EV
    Receiver Identification Number
    REF-02
    127
    Receiver Identifier
    Required
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    REF
    0600

    Version Identification

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • Update this reference number whenever a change in the version or release number affects the 835. (This is not the ANSI ASCX12 version number as reported in the GS segment.)
    • Required when necessary to report the version number of the adjudication system that generated the claim payments in order for the payer to resolve customer service questions from the payee. If not required by this implementation guide, do not send.
    Example
    Variants (all may be used)
    REFReceiver Identification
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    F2
    Version Code - Local
    REF-02
    127
    Version Identification Code
    Required
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    DTM
    0700

    Production Date

    OptionalMax use 1

    To specify pertinent dates and times

    Usage notes
    • If your adjudication cycle completed on Thursday and your 835 is produced on Saturday, you are required to populate this segment with Thursday's date.
    • Required when the cut off date of the adjudication system remittance run is different from the date of the 835 as identified in the related GS04 element. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
    Example
    DTM-01
    374
    Date Time Qualifier
    Required

    Code specifying type of date or time, or both date and time

    405
    Production
    DTM-02
    373
    Production Date
    Required
    CCYYMMDD format

    Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

    Usage notes
    • Report the end date for the adjudication production cycle for claims included in this 835.
    1000B Payee Identification Loop
    RequiredMax 1
    Variants (all may be used)
    1000APayer Identification Loop
    N1
    0800

    Payee Identification

    RequiredMax use 1

    To identify a party by type of organization, name, and code

    Usage notes
    • Use this N1 loop to provide the name/address information of the payee. The identifying reference number is provided in N104.
    Example
    N1-01
    98
    Entity Identifier Code
    Required

    Code identifying an organizational entity, a physical location, property or an individual

    PE
    Payee
    N1-02
    93
    Payee Name
    Required
    Min 1Max 60

    Free-form name

    N1-03
    66
    Identification Code Qualifier
    Required

    Code designating the system/method of code structure used for Identification Code (67)

    FI
    Federal Taxpayer's Identification Number

    Required if provider is not mandated by NPI. For individual providers as payees, use this qualifier to represent the Social Security Number.

    XV
    Centers for Medicare and Medicaid Services PlanID

    Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). This only applies in cases of post payment recovery. See section 1.10.2.16 (Post Payment Recovery) for further information.

    XX
    Centers for Medicare and Medicaid Services National Provider Identifier

    This is REQUIRED when the National Provider Identifier is mandated for use and the payee is a covered health care provider under the mandate.

    N1-04
    67
    Payee Identification Code
    Required
    Min 2Max 80

    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.
    N3
    1000

    Payee Address

    OptionalMax use 1

    To specify the location of the named party

    Usage notes
    • Required when the sender needs to communicate the payee address to a transaction receiver, e.g., a VAN or a clearinghouse. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
    Example
    N3-01
    166
    Payee Address Line
    Required
    Min 1Max 55

    Address information

    N3-02
    166
    Payee Address Line
    Optional
    Min 1Max 55

    Address information

    N4
    1100

    Payee City, State, ZIP Code

    OptionalMax use 1

    To specify the geographic place of the named party

    Usage notes
    • Required when the sender needs to communicate the payee address to a transaction receiver, e.g., a VAN or a clearinghouse. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
    Example
    Only one of Payee State Code (N4-02) or Country Subdivision Code (N4-07) may be present
    If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
    N4-01
    19
    Payee City Name
    Required
    Min 2Max 30

    Free-form text for city name

    • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
    N4-02
    156
    Payee State Code
    Optional
    Min 2Max 2

    Code (Standard State/Province) as defined by appropriate government agency

    • N402 is required only if city name (N401) is in the U.S. or Canada.
    N4-03
    116
    Payee Postal Zone or ZIP Code
    Optional
    Min 3Max 15

    Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

    N4-04
    26
    Country Code
    Optional
    Min 2Max 3

    Code identifying the country

    Usage notes
    • Use the alpha-2 country codes from Part 1 of ISO 3166.
    N4-07
    1715
    Country Subdivision Code
    Optional
    Min 1Max 3

    Code identifying the country subdivision

    Usage notes
    • Use the country subdivision codes from Part 2 of ISO 3166.
    REF
    1200

    Payee Additional Identification

    OptionalMax use >1

    To specify identifying information

    Usage notes
    • Required when identification of the payee is dependent upon an identification number beyond that supplied in the N1 segment. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    0B
    State License Number
    D3
    National Council for Prescription Drug Programs Pharmacy Number
    PQ
    Payee Identification
    TJ
    Federal Taxpayer's Identification Number

    This information must be in the N1 segment unless the National Provider ID or the Health Plan Identifier (HPID) or Other Entity Identifier (OEID) was used in N104. For individual providers as payees, use this number to represent the Social Security Number. TJ also represents the Employer Identification Number (EIN). According to the IRS, TIN and EIN can be used interchangeably.

    REF-02
    127
    Additional Payee Identifier
    Required
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    RDM
    1400

    Remittance Delivery Method

    OptionalMax use 1

    To identify remittance delivery when remittance is separate from payment

    Usage notes
    • Required when BPR01 = U or X; and the remittance is to be sent separately from the payment. The payer is responsible to provide the bank with the instructions on how to deliver the remittance information, if not required by this implementation guide, do not send.
    • Payer should coordinate this process with their Originating Depository Financial Institution (ODFI).
    Example
    RDM-01
    756
    Report Transmission Code
    Required

    Code defining timing, transmission method or format by which reports are to be sent

    BM
    By Mail

    When used, RDM02 must be used.

    When BM is used, the remittance information will be mailed to the payee at the address identified in this 1000B loop.

    EM
    E-Mail

    Use with encrypted e-mail.

    FT
    File Transfer

    Use with FTP communications.

    OL
    On-Line

    Use with secured hosted or other electronic delivery.

    RDM-02
    93
    Name
    Optional
    Min 1Max 60

    Free-form name

    • RDM02 is used to contain the name of a third party processor if needed, who would be the first recipient of the remittance.
    Usage notes
    • When BM is used, the remittance information will be mailed to the attention of this person at the payee's address identified in this 1000B loop.
    RDM-03
    364
    Communication Number
    Optional
    Min 1Max 256

    Complete communications number including country or area code when applicable

    • RDM03 contains the operative communication number for the delivery method specified in RDM01 (i.e. fax phone number and mail address).
    Usage notes
    • Contains URL web address or e-mail address.
    1000A Payer Identification Loop
    RequiredMax 1
    Variants (all may be used)
    1000BPayee Identification Loop
    N1
    0800

    Payer Identification

    RequiredMax use 1

    To identify a party by type of organization, name, and code

    Usage notes
    • Use this N1 loop to provide the name/address information for the payer.
    • The payer's secondary identifying reference number is provided in N104, if necessary.
    Example
    At least one of Payer Name (N1-02) or Identification Code Qualifier (N1-03) is required
    If either Identification Code Qualifier (N1-03) or Payer Identifier (N1-04) is present, then the other is required
    N1-01
    98
    Entity Identifier Code
    Required

    Code identifying an organizational entity, a physical location, property or an individual

    PR
    Payer
    N1-02
    93
    Payer Name
    Required
    Min 1Max 60

    Free-form name

    N1-03
    66
    Identification Code Qualifier
    Optional

    Code designating the system/method of code structure used for Identification Code (67)

    XV
    Centers for Medicare and Medicaid Services PlanID

    Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

    N1-04
    67
    Payer Identifier
    Optional
    Min 2Max 80

    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.
    N3
    1000

    Payer Address

    RequiredMax use 1

    To specify the location of the named party

    Example
    N3-01
    166
    Payer Address Line
    Required
    Min 1Max 55

    Address information

    N3-02
    166
    Payer Address Line
    Optional
    Min 1Max 55

    Address information

    N4
    1100

    Payer City, State, ZIP Code

    RequiredMax use 1

    To specify the geographic place of the named party

    Example
    Only one of Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present
    If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
    N4-01
    19
    Payer City Name
    Required
    Min 2Max 30

    Free-form text for city name

    • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
    N4-02
    156
    Payer State Code
    Optional
    Min 2Max 2

    Code (Standard State/Province) as defined by appropriate government agency

    • N402 is required only if city name (N401) is in the U.S. or Canada.
    N4-03
    116
    Payer Postal Zone or ZIP Code
    Optional
    Min 3Max 15

    Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

    N4-04
    26
    Country Code
    Optional
    Min 2Max 3

    Code identifying the country

    Usage notes
    • Use the alpha-2 country codes from Part 1 of ISO 3166.
    N4-07
    1715
    Country Subdivision Code
    Optional
    Min 1Max 3

    Code identifying the country subdivision

    Usage notes
    • Use the country subdivision codes from Part 2 of ISO 3166.
    REF
    1200

    Additional Payer Identification

    OptionalMax use 4

    To specify identifying information

    Usage notes
    • The ID available in the TRN and N1 segments must be used before using the REF segment.
    • Required when additional payer identification numbers beyond those in the TRN and Payer N1 segments are needed. If not required by this implementation guide, may be sent at sender's discretion, but cannot be required by the receiver.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    2U
    Payer Identification Number

    For Medicare carriers or intermediaries, use this qualifier for the Medicare carrier or intermediary ID number. For Blue Cross and Blue Shield Plans, use this qualifier for the Blue Cross Blue Shield association plan code.

    EO
    Submitter Identification Number

    This is required when the original transaction sender is not the payer or is identified by an identifier other than those already provided. This is not updated by third parties between the payer and the payee. An example of a use for this qualifier is when identifying a clearinghouse that created the 835 when the health plan sent a proprietary format to the clearinghouse.

    HI
    Health Industry Number (HIN)
    NF
    National Association of Insurance Commissioners (NAIC) Code

    This is the preferred value when identifying the payer.

    REF-02
    127
    Additional Payer Identifier
    Required
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    PER
    1300

    Payer Business Contact Information

    OptionalMax use 1

    To identify a person or office to whom administrative communications should be directed

    Usage notes
    • When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800) 555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number.
    • Required when there is a business contact area that would apply to this remittance and all the claims. If not required by this implementation guide, do not send.
    Example
    If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required
    If either Communication Number Qualifier (PER-05) or Payer Contact Communication Number (PER-06) is present, then the other is required
    If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required
    PER-01
    366
    Contact Function Code
    Required

    Code identifying the major duty or responsibility of the person or group named

    CX
    Payers Claim Office
    PER-02
    93
    Payer Contact Name
    Optional
    Min 1Max 60

    Free-form name

    Usage notes
    • Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1).
    PER-03
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

    EM
    Electronic Mail
    FX
    Facsimile
    TE
    Telephone
    PER-04
    364
    Payer Contact Communication Number
    Optional
    Min 1Max 256

    Complete communications number including country or area code when applicable

    PER-05
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

    EM
    Electronic Mail
    EX
    Telephone Extension

    When used, the value following this code is the extension for the preceding communications contact number.

    FX
    Facsimile
    TE
    Telephone
    PER-06
    364
    Payer Contact Communication Number
    Optional
    Min 1Max 256

    Complete communications number including country or area code when applicable

    PER-07
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

    EX
    Telephone Extension
    PER-08
    364
    Payer Contact Communication Number
    Optional
    Min 1Max 256

    Complete communications number including country or area code when applicable

    PER
    1300

    Payer Technical Contact Information

    RequiredMax use >1

    To identify a person or office to whom administrative communications should be directed

    Usage notes
    • Required to report technical contact information for this remittance advice.
    Example
    If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required
    If either Communication Number Qualifier (PER-05) or Payer Technical Contact Communication Number (PER-06) is present, then the other is required
    If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required
    PER-01
    366
    Contact Function Code
    Required

    Code identifying the major duty or responsibility of the person or group named

    BL
    Technical Department
    PER-02
    93
    Payer Technical Contact Name
    Optional
    Min 1Max 60

    Free-form name

    Usage notes
    • Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1).
    PER-03
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

    EM
    Electronic Mail
    TE
    Telephone

    Recommended

    UR
    Uniform Resource Locator (URL)

    Use only when there is no central telephone number for the payer entity.

    PER-04
    364
    Payer Contact Communication Number
    Optional
    Min 1Max 256

    Complete communications number including country or area code when applicable

    PER-05
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

    EM
    Electronic Mail
    EX
    Telephone Extension

    When used, the value following this code is theextension for the preceding communicationscontact number.

    FX
    Facsimile
    TE
    Telephone
    UR
    Uniform Resource Locator (URL)
    PER-06
    364
    Payer Technical Contact Communication Number
    Optional
    Min 1Max 256

    Complete communications number including country or area code when applicable

    PER-07
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

    EM
    Electronic Mail
    EX
    Telephone Extension

    When used, the value following this code is theextension for the preceding communicationscontact number.

    FX
    Facsimile
    UR
    Uniform Resource Locator (URL)
    PER-08
    364
    Payer Contact Communication Number
    Optional
    Min 1Max 256

    Complete communications number including country or area code when applicable

    PER
    1300

    Payer WEB Site

    OptionalMax use 1

    To identify a person or office to whom administrative communications should be directed

    Usage notes
    • Required when any 2110 loop Healthcare Policy REF Segment is used. If not required by this implementation guide, do not send.
    • This is a direct link to the policy location of the un-secure website.
    Example
    PER-01
    366
    Contact Function Code
    Required

    Code identifying the major duty or responsibility of the person or group named

    IC
    Information Contact
    PER-03
    365
    Communication Number Qualifier
    Required

    Code identifying the type of communication number

    UR
    Uniform Resource Locator (URL)
    PER-04
    364
    Communication Number
    Required
    Min 1Max 256

    Complete communications number including country or area code when applicable

    Usage notes
    • This is the payer's WEB site URL where providers can find policy and other related information.

    Detail

    2000 Header Number Loop
    OptionalMax >1
    LX
    0030

    Header Number

    RequiredMax use 1

    To reference a line number in a transaction set

    Usage notes
    • Required when claim/service information is being provided in the transaction. If not required by this implementation guide, do not send.
    • The purpose of LX01 is to provide an identification of a particular grouping of claims for sorting purposes.
    • In the event that claim/service information must be sorted, the LX segment must precede each series of claim level and service level segments. This number is intended to be unique within each transaction.
    Example
    LX-01
    554
    Assigned Number
    Required
    Min 1Max 6

    Number assigned for differentiation within a transaction set

    TS3
    0050

    Provider Summary Information

    OptionalMax use 1

    To supply provider-level control information

    Usage notes
    • TS301 identifies the subsidiary provider.
    • The remaining mandatory elements (TS302 through TS305) must be valid with appropriate data, as defined by the TS3 segment.
    • Only Medicare Part A uses data elements TS313, TS315, TS317, TS318 and TS320 through TS324. Each monetary amount element is for that provider for this facility type code for loop 2000.
    • Required for Medicare Part A or when payers and payees outside the Medicare Part A community need to identify provider subsidiaries whose remittance information is contained in the 835 transactions transmitted to a single provider entity [i.e., the corporate office of a hospital chain]. If not required by this implementation guide, do not send.
    Example
    TS3-01
    127
    Provider Identifier
    Required
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    • TS301 is the provider number.
    Usage notes
    • This is the provider number.
    TS3-02
    1331
    Facility Type Code
    Required
    Min 1Max 2

    Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.

    Usage notes
    • When reporting a TS3 segment for professional claims and the claims are not all for the same place of service, report a place of service of 11 (Office) as the default value. When reporting a TS3 segment for pharmaceutical claims and the claims are not all for the same place of service, report a place of service of 99 (Other unlisted facility) as the default value.
    TS3-03
    373
    Fiscal Period Date
    Required
    CCYYMMDD format

    Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

    • TS303 is the last day of the provider's fiscal year.
    Usage notes
    • Use this date for the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known, use December 31st of the current year.
    TS3-04
    380
    Total Claim Count
    Required
    Min 1Max 15

    Numeric value of quantity

    • TS304 is the total number of claims.
    Usage notes
    • This is the total number of claims.
    TS3-05
    782
    Total Claim Charge Amount
    Required
    Min 1Max 15

    Monetary amount

    • TS305 is the total of reported charges.
    Usage notes
    • This is the total reported charges for all claims.
    • Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all 782 elements.
    TS3-13
    782
    Total MSP Payer Amount
    Optional
    Min 1Max 15

    Monetary amount

    • TS313 is the total Medicare Secondary Payer (MSP) primary payer amount.
    Usage notes
    • See TR3 note 3.
    TS3-15
    782
    Total Non-Lab Charge Amount
    Optional
    Min 1Max 15

    Monetary amount

    • TS315 is the summary of non-lab charges.
    Usage notes
    • See TR3 note 3.
    TS3-17
    782
    Total HCPCS Reported Charge Amount
    Optional
    Min 1Max 15

    Monetary amount

    • TS317 is the Health Care Financing Administration Common Procedural Coding System (HCPCS) reported charges.
    Usage notes
    • See TR3 note 3.
    TS3-18
    782
    Total HCPCS Payable Amount
    Optional
    Min 1Max 15

    Monetary amount

    • TS318 is the total Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount.
    Usage notes
    • See TR3 note 3.
    TS3-20
    782
    Total Professional Component Amount
    Optional
    Min 1Max 15

    Monetary amount

    • TS320 is the total professional component amount.
    Usage notes
    • The professional component amount must also be reported in the CAS segment with a Claim Adjustment Reason Code value of 89.
    • See TR3 note 3.
    TS3-21
    782
    Total MSP Patient Liability Met Amount
    Optional
    Min 1Max 15

    Monetary amount

    • TS321 is the total Medicare Secondary Payer (MSP) patient liability met.
    Usage notes
    • See TR3 note 3.
    TS3-22
    782
    Total Patient Reimbursement Amount
    Optional
    Min 1Max 15

    Monetary amount

    • TS322 is the total patient reimbursement.
    Usage notes
    • See TR3 note 3.
    TS3-23
    380
    Total PIP Claim Count
    Optional
    Min 1Max 15

    Numeric value of quantity

    • TS323 is the total periodic interim payment (PIP) number of claims.
    Usage notes
    • See TR3 note 3.
    TS3-24
    782
    Total PIP Adjustment Amount
    Optional
    Min 1Max 15

    Monetary amount

    • TS324 is total periodic interim payment (PIP) adjustment.
    Usage notes
    • See TR3 note 3.
    TS2
    0070

    Provider Supplemental Summary Information

    OptionalMax use 1

    To provide supplemental summary control information by provider fiscal year and bill type

    Usage notes
    • This segment provides summary information specific to an iteration of the LX loop (Table 2).
    • Each element represents the total value for the provider/bill type combination in this loop 2000 iteration.
    • Required for Medicare Part A. If not required by this implementation guide, do not send.
    Example
    TS2-01
    782
    Total DRG Amount
    Optional
    Min 1Max 15

    Monetary amount

    • TS201 is the total diagnosis related group (DRG) amount.
    Usage notes
    • This includes: operating federal-specific amount, operating hospital-specific amount, operating Indirect Medical Education amount, and operating Disproportionate Share Hospital amount. It does not include any operating outlier amount.
    • See TR3 note 2.
    TS2-02
    782
    Total Federal Specific Amount
    Optional
    Min 1Max 15

    Monetary amount

    • TS202 is the total federal specific amount.
    Usage notes
    • See TR3 note 2.
    TS2-03
    782
    Total Hospital Specific Amount
    Optional
    Min 1Max 15

    Monetary amount

    • TS203 is the total hospital specific amount.
    Usage notes
    • See TR3 note 2.
    TS2-04
    782
    Total Disproportionate Share Amount
    Optional
    Min 1Max 15

    Monetary amount

    • TS204 is the total disproportionate share amount.
    Usage notes
    • See TR3 note 2.
    TS2-05
    782
    Total Capital Amount
    Optional
    Min 1Max 15

    Monetary amount

    • TS205 is the total capital amount.
    Usage notes
    • This includes: capital federal-specfic amount, hospital federal-specfic amount, hold harmless amount, Indirect Medical Education amount, Disproportionate Share Hospital amount, and the exception amount. It does not include any capital outlier amount.
    • See TR3 note 2.
    TS2-06
    782
    Total Indirect Medical Education Amount
    Optional
    Min 1Max 15

    Monetary amount

    • TS206 is the total indirect medical education amount.
    Usage notes
    • See TR3 note 2.
    TS2-07
    380
    Total Outlier Day Count
    Optional
    Min 1Max 15

    Numeric value of quantity

    • TS207 is the total number of outlier days.
    Usage notes
    • See TR3 note 2.
    TS2-08
    782
    Total Day Outlier Amount
    Optional
    Min 1Max 15

    Monetary amount

    • TS208 is the total day outlier amount.
    Usage notes
    • See TR3 note 2.
    TS2-09
    782
    Total Cost Outlier Amount
    Optional
    Min 1Max 15

    Monetary amount

    • TS209 is the total cost outlier amount.
    Usage notes
    • See TR3 note 2.
    TS2-10
    380
    Average DRG Length of Stay
    Optional
    Min 1Max 15

    Numeric value of quantity

    • TS210 is the diagnosis related group (DRG) average length of stay.
    Usage notes
    • See TR3 note 2.
    TS2-11
    380
    Total Discharge Count
    Optional
    Min 1Max 15

    Numeric value of quantity

    • TS211 is the total number of discharges.
    Usage notes
    • This is the discharge count produced by PPS PRICER SOFTWARE.
    • See TR3 note 2.
    TS2-12
    380
    Total Cost Report Day Count
    Optional
    Min 1Max 15

    Numeric value of quantity

    • TS212 is the total number of cost report days.
    Usage notes
    • See TR3 note 2.
    TS2-13
    380
    Total Covered Day Count
    Optional
    Min 1Max 15

    Numeric value of quantity

    • TS213 is the total number of covered days.
    Usage notes
    • See TR3 note 2.
    TS2-14
    380
    Total Noncovered Day Count
    Optional
    Min 1Max 15

    Numeric value of quantity

    • TS214 is total number of non-covered days.
    Usage notes
    • See TR3 note 2.
    TS2-15
    782
    Total MSP Pass-Through Amount
    Optional
    Min 1Max 15

    Monetary amount

    • TS215 is the total Medicare Secondary Payer (MSP) pass- through amount calculated for a non-Medicare payer.
    Usage notes
    • See TR3 note 2.
    TS2-16
    380
    Average DRG weight
    Optional
    Min 1Max 15

    Numeric value of quantity

    • TS216 is the average diagnosis-related group (DRG) weight.
    Usage notes
    • See TR3 note 2.
    TS2-17
    782
    Total PPS Capital FSP DRG Amount
    Optional
    Min 1Max 15

    Monetary amount

    • TS217 is the total prospective payment system (PPS) capital, federal-specific portion, diagnosis-related group (DRG) amount.
    Usage notes
    • See TR3 note 2.
    TS2-18
    782
    Total PPS Capital HSP DRG Amount
    Optional
    Min 1Max 15

    Monetary amount

    • TS218 is the total prospective payment system (PPS) capital, hospital-specific portion, diagnosis-related group (DRG) amount.
    Usage notes
    • See TR3 note 2.
    TS2-19
    782
    Total PPS DSH DRG Amount
    Optional
    Min 1Max 15

    Monetary amount

    • TS219 is the total prospective payment system (PPS) disproportionate share, hospital diagnosis-related group (DRG) amount.
    Usage notes
    • See TR3 note 2.
    2100 Claim Payment Information Loop
    RequiredMax >1
    CLP
    0100

    Claim Payment Information

    RequiredMax use 1

    To supply information common to all services of a claim

    Usage notes
    • For CLP segment occurrence limitations, see section 1.3.2, Other Usage Limitations.
    Example
    CLP-01
    1028
    Patient Control Number
    Required
    Min 1Max 38

    Identifier used to track a claim from creation by the health care provider through payment

    Usage notes
    • Use this number for the patient control number assigned by the provider. If the patient control number is not present on the incoming claim, enter a single zero. The value in CLP01 must be identical to any value received as a Claim Submitter's Identifier on the original claim (CLM01 of the ANSI ASC X12 837, if applicable). This data element is the primary key for posting the remittance information into the provider's database. In the case of pharmacy claims, this is the prescription reference number (field 402-02 in the NCPDP 5.1 format).
    CLP-02
    1029
    Claim Status Code
    Required

    Code identifying the status of an entire claim as assigned by the payor, claim review organization or repricing organization

    Usage notes
    • To determine the full claim status reference Claim adjustment reason codes in the CAS segment in conjunction with this claim status code.
    1
    Processed as Primary

    Use this code if the claim was adjudicated by the current payer as primary regardless of whether any part of the claim was paid.

    2
    Processed as Secondary

    Use this code if the claim was adjudicated by the current payer as secondary regardless of whether any part of the claim was paid.

    3
    Processed as Tertiary

    Use this code if the claim was adjudicated by the current payer as tertiary (or subsequent) regardless of whether any part of the claim was paid.

    4
    Denied

    Usage of this code would apply if the Patient/Subscriber is not recognized, and the claim was not forwarded to another payer.

    19
    Processed as Primary, Forwarded to Additional Payer(s)

    When this code is used, the Crossover Carrier Name NM1 segment is required.

    20
    Processed as Secondary, Forwarded to Additional Payer(s)

    When this code is used, the Crossover Carrier Name NM1 segment is required.

    21
    Processed as Tertiary, Forwarded to Additional Payer(s)

    When this code is used, the Crossover Carrier Name NM1 segment is required.

    22
    Reversal of Previous Payment

    See section 1.10.2.8 for usage information.

    23
    Not Our Claim, Forwarded to Additional Payer(s)

    Usage of this code would apply if the patient/subscriber is not recognized, the claim was not adjudicated by the payer, but other payers are known and the claim has been forwarded to another payer. When this code is used, the Crossover Carrier Name NM1 segment is required.

    25
    Predetermination Pricing Only - No Payment
    CLP-03
    782
    Total Claim Charge Amount
    Required
    Min 1Max 15

    Monetary amount

    • CLP03 is the amount of submitted charges this claim.
    Usage notes
    • See 1.10.2.1, Balancing, in this implementation guide for additional information.
    • Use this monetary amount for the submitted charges for this claim. The amount can be positive, zero or negative. An example of a situation with a negative charge is a reversal claim. See section 1.10.2.8 for additional information.
    • Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements.
    CLP-04
    782
    Claim Payment Amount
    Required
    Min 1Max 15

    Monetary amount

    • CLP04 is the amount paid this claim.
    Usage notes
    • See 1.10.2.1, Balancing, in this implementation guide for additional information. See section 1.10.2.9 for information about interest considerations.
    • Use this monetary amount for the amount paid for this claim. It can be positive, zero or negative, but the value in BPR02 may not be negative.
    CLP-05
    782
    Patient Responsibility Amount
    Optional
    Min 1Max 15

    Monetary amount

    • CLP05 is the patient responsibility amount.
    Usage notes
    • Amounts in CLP05 must have supporting adjustments reflected in CAS segments at the 2100 (CLP) or 2110 (SVC) loop level with a Claim Adjustment Group (CAS01) code of PR (Patient Responsibility).
    • Use this monetary amount for the payer's statement of the patient responsibility amount for this claim, which can include such items as deductible, non-covered services, co-pay and co-insurance. This is not used for reversals. See section 1.10.2.8, Reversals and Corrections, for additional information.
    CLP-06
    1032
    Claim Filing Indicator Code
    Required

    Code identifying type of claim

    Usage notes
    • For many providers to electronically post the 835 remittance data to their patient accounting systems without human intervention, a unique, provider-specific insurance plan code is needed. This code allows the provider to separately identify and manage the different product lines or contractual arrangements between the payer and the provider. Because most payers maintain the same Originating Company Identifier in the TRN03 or BPR10 for all product lines or contractual relationships, the CLP06 is used by the provider as a table pointer in combination with the TRN03 or BPR10 to identify the unique, provider-specific insurance plan code needed to post the payment without human intervention. The value should mirror the value received in the original claim (2-005 SBR09 of the 837), if applicable, or provide the value as assigned or edited by the payer. For example the BL from the SBR09 in the 837 would be returned as 12, 13, 15, in the 835 when more details are known. The 837 SBR09 code CI (Commercial Insurance) is generic, if through adjudication the specific type of plan is obtained a more specific code must be returned in the 835.
    • The 837 and 835 transaction code lists for this element are not identical by design. There are some business differences between the two transactions. When a code from the 837 is not available in the 835 another valid code from the 835 must be assigned by the payer.
    12
    Preferred Provider Organization (PPO)

    This code is also used for Blue Cross/Blue Shield participating provider arrangements.

    13
    Point of Service (POS)
    14
    Exclusive Provider Organization (EPO)
    15
    Indemnity Insurance

    This code is also used for Blue Cross/Blue Shield non-participating provider arrangements.

    16
    Health Maintenance Organization (HMO) Medicare Risk
    17
    Dental Maintenance Organization
    AM
    Automobile Medical
    CH
    Champus
    DS
    Disability
    HM
    Health Maintenance Organization
    LM
    Liability Medical
    MA
    Medicare Part A
    MB
    Medicare Part B
    MC
    Medicaid
    OF
    Other Federal Program

    Use this code for the Black Lung Program.

    TV
    Title V
    VA
    Veterans Affairs Plan
    WC
    Workers' Compensation Health Claim
    ZZ
    Mutually Defined
    CLP-07
    127
    Payer Claim Control Number
    Required
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    • CLP07 is the payer's internal control number.
    Usage notes
    • Use this number for the payer's internal control number. This number must apply to the entire claim.
    CLP-08
    1331
    Facility Type Code
    Optional
    Min 1Max 2

    Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.

    Usage notes
    • Since professional or dental claims can have different place of service codes for services within a single claim, default to the place of service of the first service line when the service lines are not all for the same place of service.
    • This number was received in CLM05-1 of the 837 claim.
    CLP-09
    1325
    Claim Frequency Code
    Optional
    Min 1Max 1

    Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type

    Usage notes
    • This number was received in CLM05-3 of the 837 Claim.
    CLP-11
    1354
    Diagnosis Related Group (DRG) Code
    Optional
    Min 1Max 4

    Code indicating a patient's diagnosis group based on a patient's illness, diseases, and medical problems

    CLP-12
    380
    Diagnosis Related Group (DRG) Weight
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CLP12 is the diagnosis-related group (DRG) weight.
    Usage notes
    • This is the adjudicated DRG Weight.
    CLP-13
    954
    Discharge Fraction
    Optional
    Min 1Max 10

    Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)

    • CLP13 is the discharge fraction.
    Usage notes
    • This is the adjudicated discharge fraction.
    CAS
    0200

    Claim Adjustment

    OptionalMax use 99

    To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

    Usage notes
    • Payers must use this CAS segment to report claim level adjustments that cause the amount paid to differ from the amount originally charged. See 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information.
    • See the SVC TR3 Note #1 for details about per diem adjustments.
    • A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment must be the first non-zero adjustment and is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).
    • Required when dollar amounts and/or quantities are being adjusted at the claim level. If not required by this implementation guide, do not send.
    Example
    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
    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
    Required

    Code identifying the general category of payment adjustment

    Usage notes
    • Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.)
    CO
    Contractual Obligations

    Use this code when a joint payer/payee contractual agreement or a regulatory requirement resulted in an adjustment.

    OA
    Other adjustments

    Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13.

    PI
    Payor Initiated Reductions

    Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments).

    PR
    Patient Responsibility
    CAS-02
    1034
    Adjustment Reason Code
    Required
    Min 1Max 5

    Code identifying the detailed reason the adjustment was made

    Usage notes
    • Required to report a non-zero adjustment applied at the claim level for the claim adjustment group code reported in CAS01.
    CAS-03
    782
    Adjustment Amount
    Required
    Min 1Max 15

    Monetary amount

    • CAS03 is the amount of adjustment.
    Usage notes
    • Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in CLP04.
    • Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements.
    CAS-04
    380
    Adjustment Quantity
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CAS04 is the units of service being adjusted.
    Usage notes
    • See section 1.10.2.4.1 for additional information.
    • A positive value decreases the covered days, and a negative number increases the covered days.
    CAS-05
    1034
    Adjustment Reason Code
    Optional
    Min 1Max 5

    Code identifying the detailed reason the adjustment was made

    CAS-06
    782
    Adjustment Amount
    Optional
    Min 1Max 15

    Monetary amount

    • CAS06 is the amount of the adjustment.
    Usage notes
    • See CAS03.
    CAS-07
    380
    Adjustment Quantity
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CAS07 is the units of service being adjusted.
    Usage notes
    • See CAS04.
    CAS-08
    1034
    Adjustment Reason Code
    Optional
    Min 1Max 5

    Code identifying the detailed reason the adjustment was made

    CAS-09
    782
    Adjustment Amount
    Optional
    Min 1Max 15

    Monetary amount

    • CAS09 is the amount of the adjustment.
    Usage notes
    • See CAS03.
    CAS-10
    380
    Adjustment Quantity
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CAS10 is the units of service being adjusted.
    Usage notes
    • See CAS04.
    CAS-11
    1034
    Adjustment Reason Code
    Optional
    Min 1Max 5

    Code identifying the detailed reason the adjustment was made

    CAS-12
    782
    Adjustment Amount
    Optional
    Min 1Max 15

    Monetary amount

    • CAS12 is the amount of the adjustment.
    Usage notes
    • See CAS03.
    CAS-13
    380
    Adjustment Quantity
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CAS13 is the units of service being adjusted.
    Usage notes
    • See CAS04.
    CAS-14
    1034
    Adjustment Reason Code
    Optional
    Min 1Max 5

    Code identifying the detailed reason the adjustment was made

    CAS-15
    782
    Adjustment Amount
    Optional
    Min 1Max 15

    Monetary amount

    • CAS15 is the amount of the adjustment.
    Usage notes
    • See CAS03.
    CAS-16
    380
    Adjustment Quantity
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CAS16 is the units of service being adjusted.
    Usage notes
    • See CAS04.
    CAS-17
    1034
    Adjustment Reason Code
    Optional
    Min 1Max 5

    Code identifying the detailed reason the adjustment was made

    CAS-18
    782
    Adjustment Amount
    Optional
    Min 1Max 15

    Monetary amount

    • CAS18 is the amount of the adjustment.
    Usage notes
    • See CAS03.
    CAS-19
    380
    Adjustment Quantity
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CAS19 is the units of service being adjusted.
    Usage notes
    • See CAS04.
    NM1
    0300

    Corrected Patient/Insured Name

    OptionalMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • Since the patient is always the insured for Medicare and Medicaid, this segment always provides corrected patient information for Medicare and Medicaid. For other carriers, this will always be the corrected insured information.
    • Required when needed to provide corrected information about the patient or insured. If not required by this implementation guide, do not send.
    Example
    If either Identification Code Qualifier (NM1-08) or Corrected Insured Identification Indicator (NM1-09) is present, then the other is required
    NM1-01
    98
    Entity Identifier Code
    Required

    Code identifying an organizational entity, a physical location, property or an individual

    74
    Corrected Insured
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

    • NM102 qualifies NM103.
    1
    Person
    2
    Non-Person Entity
    NM1-03
    1035
    Corrected Patient or Insured Last Name
    Optional
    Min 1Max 60

    Individual last name or organizational name

    NM1-04
    1036
    Corrected Patient or Insured First Name
    Optional
    Min 1Max 35

    Individual first name

    NM1-05
    1037
    Corrected Patient or Insured Middle Name
    Optional
    Min 1Max 25

    Individual middle name or initial

    Usage notes
    • If this data element is used and contains only one character, it is assumed to represent the middle initial.
    NM1-07
    1039
    Corrected Patient or Insured Name Suffix
    Optional
    Min 1Max 10

    Suffix to individual name

    NM1-08
    66
    Identification Code Qualifier
    Optional

    Code designating the system/method of code structure used for Identification Code (67)

    C
    Insured's Changed Unique Identification Number
    NM1-09
    67
    Corrected Insured Identification Indicator
    Optional
    Min 2Max 80

    Code identifying a party or other code

    NM1
    0300

    Corrected Priority Payer Name

    OptionalMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • Provide any reference numbers in NM109. Use of this segment identifies the priority payer. Do not use this segment when the Crossover Carrier NM1 segment is used.
    • Required when current payer believes that another payer has priority for making a payment and the claim is not being automatically transferred to that payer. If not required by this implementation guide, do not send.
    Example
    NM1-01
    98
    Entity Identifier Code
    Required

    Code identifying an organizational entity, a physical location, property or an individual

    PR
    Payer
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

    • NM102 qualifies NM103.
    2
    Non-Person Entity
    NM1-03
    1035
    Corrected Priority Payer Name
    Required
    Min 1Max 60

    Individual last name or organizational name

    NM1-08
    66
    Identification Code Qualifier
    Required

    Code designating the system/method of code structure used for Identification Code (67)

    AD
    Blue Cross Blue Shield Association Plan Code
    FI
    Federal Taxpayer's Identification Number
    NI
    National Association of Insurance Commissioners (NAIC) Identification

    This is the preferred ID unless XV is used.

    PI
    Payor Identification
    PP
    Pharmacy Processor Number
    XV
    Centers for Medicare and Medicaid Services PlanID

    Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used.

    NM1-09
    67
    Corrected Priority Payer Identification Number
    Required
    Min 2Max 80

    Code identifying a party or other code

    NM1
    0300

    Crossover Carrier Name

    OptionalMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • This segment provides information about the crossover carrier. Provide any reference numbers in NM109. The crossover carrier is defined as any payer to which the claim is transferred for further payment after being finalized by the current payer.
    • Required when the claim is transferred to another carrier or coverage (CLP02 equals 19, 20, 21 or 23). If not required by this implementation guide, do not send.
    Example
    NM1-01
    98
    Entity Identifier Code
    Required

    Code identifying an organizational entity, a physical location, property or an individual

    TT
    Transfer To
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

    • NM102 qualifies NM103.
    2
    Non-Person Entity
    NM1-03
    1035
    Crossover Carrier Name
    Required
    Min 1Max 60

    Individual last name or organizational name

    Usage notes
    • Name of the crossover carrier associated with this claim.
    NM1-08
    66
    Identification Code Qualifier
    Required

    Code designating the system/method of code structure used for Identification Code (67)

    AD
    Blue Cross Blue Shield Association Plan Code
    FI
    Federal Taxpayer's Identification Number
    NI
    National Association of Insurance Commissioners (NAIC) Identification

    This is the preferred ID unless XV is used.

    PI
    Payor Identification
    PP
    Pharmacy Processor Number
    XV
    Centers for Medicare and Medicaid Services PlanID

    Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used.

    NM1-09
    67
    Crossover Carrier Identifier
    Required
    Min 2Max 80

    Code identifying a party or other code

    NM1
    0300

    Insured Name

    OptionalMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • In the case of Medicare and Medicaid, the insured patient is always the subscriber and this segment is not used.
    • Required when the original claim reported the insured or subscriber (for example 837 2010BA loop Subscriber Name NM1 Segment) that is different from the patient. If not required by this implementation guide, do not send.
    • This segment contains the same information as reported on the claim (for example 837 2010BA loop Subscriber Name NM1 Segment when the patient was reported in the 2010CA loop Patient Name NM1 Segment).
    Example
    NM1-01
    98
    Entity Identifier Code
    Required

    Code identifying an organizational entity, a physical location, property or an individual

    IL
    Insured or Subscriber
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

    • NM102 qualifies NM103.
    1
    Person
    2
    Non-Person Entity
    NM1-03
    1035
    Subscriber Last Name
    Optional
    Min 1Max 60

    Individual last name or organizational name

    NM1-04
    1036
    Subscriber First Name
    Optional
    Min 1Max 35

    Individual first name

    NM1-05
    1037
    Subscriber Middle Name or Initial
    Optional
    Min 1Max 25

    Individual middle name or initial

    Usage notes
    • If this data element is used and contains only one character, it is assumed to represent the middle initial.
    NM1-07
    1039
    Subscriber Name Suffix
    Optional
    Min 1Max 10

    Suffix to individual name

    Usage notes
    • For example, use when necessary to differentiate between a Junior and Senior under the same contract.
    NM1-08
    66
    Identification Code Qualifier
    Required

    Code designating the system/method of code structure used for Identification Code (67)

    FI
    Federal Taxpayer's Identification Number

    Not Used when NM102=1.

    II
    Standard Unique Health Identifier for each Individual in the United States

    Use this code if mandated in a final Federal Rule.

    MI
    Member Identification Number

    The code MI is intended to identify that the subscriber's identification number as assigned by the payer will be conveyed in NM109. Payers use different terminology to convey the same number, therefore, the 835 workgroup recommends using MI (Member Identification number) to convey the same categories of numbers as represented in the 837 IGs for the inbound claims.

    NM1-09
    67
    Subscriber Identifier
    Required
    Min 2Max 80

    Code identifying a party or other code

    NM1
    0300

    Other Subscriber Name

    OptionalMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • This is the name and ID number of the other subscriber when a corrected priority payer has been identified. When used, either the name or ID must be supplied.
    • Required when a corrected priority payer has been identified in another NM1 segment AND the name or ID of the other subscriber is known. If not required by this implementation guide, do not send.
    Example
    If either Identification Code Qualifier (NM1-08) or Other Subscriber Identifier (NM1-09) is present, then the other is required
    NM1-01
    98
    Entity Identifier Code
    Required

    Code identifying an organizational entity, a physical location, property or an individual

    GB
    Other Insured
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

    • NM102 qualifies NM103.
    1
    Person
    2
    Non-Person Entity
    NM1-03
    1035
    Other Subscriber Last Name
    Optional
    Min 1Max 60

    Individual last name or organizational name

    Usage notes
    • At least one of NM103 or NM109 must be present.
    NM1-04
    1036
    Other Subscriber First Name
    Optional
    Min 1Max 35

    Individual first name

    NM1-05
    1037
    Other Subscriber Middle Name or Initial
    Optional
    Min 1Max 25

    Individual middle name or initial

    Usage notes
    • When only one character is present this is assumed to be the middle initial.
    NM1-07
    1039
    Other Subscriber Name Suffix
    Optional
    Min 1Max 10

    Suffix to individual name

    NM1-08
    66
    Identification Code Qualifier
    Optional

    Code designating the system/method of code structure used for Identification Code (67)

    FI
    Federal Taxpayer's Identification Number

    Not Used when NM102=1.

    II
    Standard Unique Health Identifier for each Individual in the United States

    Use this code if mandated in a final Federal Rule.

    MI
    Member Identification Number

    Use this code when supplying the number used for identification of the subscriber in NM109.

    NM1-09
    67
    Other Subscriber Identifier
    Optional
    Min 2Max 80

    Code identifying a party or other code

    Usage notes
    • At least one of NM103 or NM109 must be present.
    NM1
    0300

    Patient Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • Provide the patient's identification number in NM109.
    • This segment must provide the information from the original claim. For example, when the claim is submitted as an ASC X12 837 transaction, this is the 2010CA loop NM1 Patient Name Segment unless not present on the original claim, then it is the 2010BA loop NM1 Subscriber name segment.
    • The Corrected Patient/Insured Name NM1 segment identifies the adjudicated Insured Name and ID information if different than what was submitted on the claim.
    Example
    If either Identification Code Qualifier (NM1-08) or Patient Identifier (NM1-09) is present, then the other is required
    NM1-01
    98
    Entity Identifier Code
    Required

    Code identifying an organizational entity, a physical location, property or an individual

    QC
    Patient
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

    • NM102 qualifies NM103.
    1
    Person
    NM1-03
    1035
    Patient Last Name
    Optional
    Min 1Max 60

    Individual last name or organizational name

    NM1-04
    1036
    Patient First Name
    Optional
    Min 1Max 35

    Individual first name

    NM1-05
    1037
    Patient Middle Name or Initial
    Optional
    Min 1Max 25

    Individual middle name or initial

    Usage notes
    • If this data element is used and contains only one character, it is assumed to represent the middle initial.
    NM1-07
    1039
    Patient Name Suffix
    Optional
    Min 1Max 10

    Suffix to individual name

    Usage notes
    • An example of this is when a Junior and Senior are covered under the same subscriber.
    NM1-08
    66
    Identification Code Qualifier
    Optional

    Code designating the system/method of code structure used for Identification Code (67)

    34
    Social Security Number
    HN
    Health Insurance Claim (HIC) Number
    II
    Standard Unique Health Identifier for each Individual in the United States

    Use this code if mandated in a final Federal Rule.

    MI
    Member Identification Number
    MR
    Medicaid Recipient Identification Number
    NM1-09
    67
    Patient Identifier
    Optional
    Min 2Max 80

    Code identifying a party or other code

    NM1
    0300

    Service Provider Name

    OptionalMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • This segment provides information about the rendering provider. An identification number is provided in NM109.
    • This information is provided to facilitate identification of the claim within a payee's system. Other providers (e.g., Referring provider, supervising provider) related to the claim but not directly related to the payment are not supported and are not necessary for claim identification.
    • Required when the rendering provider is different from the payee. If not required by this implementation guide, do not send.
    Example
    NM1-01
    98
    Entity Identifier Code
    Required

    Code identifying an organizational entity, a physical location, property or an individual

    82
    Rendering Provider
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

    • NM102 qualifies NM103.
    1
    Person
    2
    Non-Person Entity
    NM1-03
    1035
    Rendering Provider Last or Organization Name
    Optional
    Min 1Max 60

    Individual last name or organizational name

    NM1-04
    1036
    Rendering Provider First Name
    Optional
    Min 1Max 35

    Individual first name

    NM1-05
    1037
    Rendering Provider Middle Name or Initial
    Optional
    Min 1Max 25

    Individual middle name or initial

    Usage notes
    • If this data element is used and contains only one character, it represents the middle initial.
    NM1-07
    1039
    Rendering Provider Name Suffix
    Optional
    Min 1Max 10

    Suffix to individual name

    NM1-08
    66
    Identification Code Qualifier
    Required

    Code designating the system/method of code structure used for Identification Code (67)

    BD
    Blue Cross Provider Number
    BS
    Blue Shield Provider Number
    FI
    Federal Taxpayer's Identification Number

    This is the preferred ID until the National Provider ID is mandated and applicable.
    For individual providers as payees, use this qualifier to represent the Social Security Number.

    MC
    Medicaid Provider Number
    PC
    Provider Commercial Number
    SL
    State License Number
    UP
    Unique Physician Identification Number (UPIN)
    XX
    Centers for Medicare and Medicaid Services National Provider Identifier

    Required value if the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate. Otherwise, one of the other listed codes may be used.

    NM1-09
    67
    Rendering Provider Identifier
    Required
    Min 2Max 80

    Code identifying a party or other code

    MIA
    0330

    Inpatient Adjudication Information

    OptionalMax use 1

    To provide claim-level data related to the adjudication of Medicare inpatient claims

    Usage notes
    • When used outside of the Medicare and Medicaid community only MIA01, 05, 20, 21, 22 and 23 may be used.
    • Either MIA or MOA may appear, but not both.
    • This segment must not be used for covered days or lifetime reserve days. For covered or lifetime reserve days, use the Supplemental Claim Information Quantities Segment in the Claim Payment Loop.
    • All situational quantities and/or monetary amounts in this segment are required when the value of the item is different than zero.
    • Required for all inpatient claims when there is a need to report Remittance Advice Remark Codes at the claim level or, the claim is paid by Medicare or Medicaid under the Prospective Payment System (PPS). If not required by this implementation guide, do not send.
    Example
    MIA-01
    380
    Covered Days or Visits Count
    Required
    Min 1Max 15

    Numeric value of quantity

    • MIA01 is the covered days.
    Usage notes
    • Implementers utilizing the MIA segment always transmit the number zero. See the QTY segment at the claim level for covered days or visits count.
    MIA-02
    782
    PPS Operating Outlier Amount
    Optional
    Min 1Max 15

    Monetary amount

    • MIA02 is the Prospective Payment System (PPS) Operating Outlier amount.
    Usage notes
    • See TR3 note 4.
    • Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements.
    MIA-03
    380
    Lifetime Psychiatric Days Count
    Optional
    Min 1Max 15

    Numeric value of quantity

    • MIA03 is the lifetime psychiatric days.
    MIA-04
    782
    Claim DRG Amount
    Optional
    Min 1Max 15

    Monetary amount

    • MIA04 is the Diagnosis Related Group (DRG) amount.
    MIA-05
    127
    Claim Payment Remark Code
    Optional
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    • MIA05 is the Claim Payment Remark Code. See Code Source 411.
    MIA-06
    782
    Claim Disproportionate Share Amount
    Optional
    Min 1Max 15

    Monetary amount

    • MIA06 is the disproportionate share amount.
    MIA-07
    782
    Claim MSP Pass-through Amount
    Optional
    Min 1Max 15

    Monetary amount

    • MIA07 is the Medicare Secondary Payer (MSP) pass-through amount.
    MIA-08
    782
    Claim PPS Capital Amount
    Optional
    Min 1Max 15

    Monetary amount

    • MIA08 is the total Prospective Payment System (PPS) capital amount.
    MIA-09
    782
    PPS-Capital FSP DRG Amount
    Optional
    Min 1Max 15

    Monetary amount

    • MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount.
    MIA-10
    782
    PPS-Capital HSP DRG Amount
    Optional
    Min 1Max 15

    Monetary amount

    • MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount.
    MIA-11
    782
    PPS-Capital DSH DRG Amount
    Optional
    Min 1Max 15

    Monetary amount

    • MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount.
    MIA-12
    782
    Old Capital Amount
    Optional
    Min 1Max 15

    Monetary amount

    • MIA12 is the old capital amount.
    MIA-13
    782
    PPS-Capital IME amount
    Optional
    Min 1Max 15

    Monetary amount

    • MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount.
    MIA-14
    782
    PPS-Operating Hospital Specific DRG Amount
    Optional
    Min 1Max 15

    Monetary amount

    • MIA14 is hospital specific Diagnosis Related Group (DRG) Amount.
    MIA-15
    380
    Cost Report Day Count
    Optional
    Min 1Max 15

    Numeric value of quantity

    • MIA15 is the cost report days.
    MIA-16
    782
    PPS-Operating Federal Specific DRG Amount
    Optional
    Min 1Max 15

    Monetary amount

    • MIA16 is the federal specific Diagnosis Related Group (DRG) amount.
    MIA-17
    782
    Claim PPS Capital Outlier Amount
    Optional
    Min 1Max 15

    Monetary amount

    • MIA17 is the Prospective Payment System (PPS) Capital Outlier amount.
    MIA-18
    782
    Claim Indirect Teaching Amount
    Optional
    Min 1Max 15

    Monetary amount

    • MIA18 is the indirect teaching amount.
    MIA-19
    782
    Nonpayable Professional Component Amount
    Optional
    Min 1Max 15

    Monetary amount

    • MIA19 is the professional component amount billed but not payable.
    MIA-20
    127
    Claim Payment Remark Code
    Optional
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    • MIA20 is the Claim Payment Remark Code. See Code Source 411.
    MIA-21
    127
    Claim Payment Remark Code
    Optional
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    • MIA21 is the Claim Payment Remark Code. See Code Source 411.
    MIA-22
    127
    Claim Payment Remark Code
    Optional
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    • MIA22 is the Claim Payment Remark Code. See Code Source 411.
    MIA-23
    127
    Claim Payment Remark Code
    Optional
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    • MIA23 is the Claim Payment Remark Code. See Code Source 411.
    MIA-24
    782
    PPS-Capital Exception Amount
    Optional
    Min 1Max 15

    Monetary amount

    • MIA24 is the capital exception amount.
    MOA
    0350

    Outpatient Adjudication Information

    OptionalMax use 1

    To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting

    Usage notes
    • Required for outpatient/professional claims where there is a need to report a Remittance Advice Remark Code at the claim level or when the payer is Medicare or Medicaid and MOA01, 02, 08 or 09 are non-zero. If not required by this implementation guide, do not send.
    • Either MIA or MOA may appear, but not both.
    • All situational quantities and/or monetary amounts in this segment are;required when the value of the item is different than zero.
    Example
    MOA-01
    954
    Reimbursement Rate
    Optional
    Min 1Max 10

    Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)

    • MOA01 is the reimbursement rate.
    MOA-02
    782
    Claim HCPCS Payable Amount
    Optional
    Min 1Max 15

    Monetary amount

    • MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount.
    Usage notes
    • Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements.
    MOA-03
    127
    Claim Payment Remark Code
    Optional
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    • MOA03 is the Claim Payment Remark Code. See Code Source 411.
    MOA-04
    127
    Claim Payment Remark Code
    Optional
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    • MOA04 is the Claim Payment Remark Code. See Code Source 411.
    MOA-05
    127
    Claim Payment Remark Code
    Optional
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    • MOA05 is the Claim Payment Remark Code. See Code Source 411.
    MOA-06
    127
    Claim Payment Remark Code
    Optional
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    • MOA06 is the Claim Payment Remark Code. See Code Source 411.
    MOA-07
    127
    Claim Payment Remark Code
    Optional
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    • MOA07 is the Claim Payment Remark Code. See Code Source 411.
    MOA-08
    782
    Claim ESRD Payment Amount
    Optional
    Min 1Max 15

    Monetary amount

    • MOA08 is the End Stage Renal Disease (ESRD) payment amount.
    MOA-09
    782
    Nonpayable Professional Component Amount
    Optional
    Min 1Max 15

    Monetary amount

    • MOA09 is the professional component amount billed but not payable.
    REF
    0400

    Other Claim Related Identification

    OptionalMax use 5

    To specify identifying information

    Usage notes
    • Required when additional reference numbers specific to the claim in the CLP segment are provided to identify information used in the process of adjudicating this claim. If not required by this implementation guide, do not send.
    Example
    Variants (all may be used)
    REFRendering Provider Identification
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    1L
    Group or Policy Number

    Use this code when conveying the Group Number in REF02.

    1W
    Member Identification Number
    6P
    Group Number

    This is the Other Insured Group Number. This is required when a Corrected Priority Payer is identified in the NM1 segment and the Group Number of the other insured for that payer is known.

    9A
    Repriced Claim Reference Number
    9C
    Adjusted Repriced Claim Reference Number
    28
    Employee Identification Number
    BB
    Authorization Number

    Use this qualifier only when supplying an authorization number that was assigned by the adjudication process and was not provided prior to the services. Do not use this qualifier when reporting the same number as reported in the claim as the prior authorization or pre-authorization number.

    CE
    Class of Contract Code

    See section 1.10.2.15 for information on the use of Class of Contract Code.

    EA
    Medical Record Identification Number
    F8
    Original Reference Number

    When this is a correction claim and CLP07 does not equal the CLP07 value from the original claim payment, one iteration of this REF segment using this qualifier is REQUIRED to identify the original claim CLP07 value in REF02. See section 1.10.2.8, Reversals and Corrections, for additional information.

    G1
    Prior Authorization Number

    Use this qualifier when reporting the number received with the original claim as a pre-authorization number (in the 837 that was at table 2, position 180, REF segment, using the same qualifier of G1).

    G3
    Predetermination of Benefits Identification Number
    IG
    Insurance Policy Number

    Use this code when conveying the Policy Number in REF02.

    SY
    Social Security Number
    REF-02
    127
    Other Claim Related Identifier
    Required
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    REF
    0400

    Rendering Provider Identification

    OptionalMax use 10

    To specify identifying information

    Usage notes
    • The NM1 segment always contains the primary reference number.
    • Required when additional rendering provider identification numbers not already reported in the Provider NM1 segment for this claim were submitted on the original claim and impacted adjudication. If not required by this implementation guide, do not send.
    Example
    Variants (all may be used)
    REFOther Claim Related Identification
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    0B
    State License Number
    1A
    Blue Cross Provider Number
    1B
    Blue Shield Provider Number
    1C
    Medicare Provider Number
    1D
    Medicaid Provider Number
    1G
    Provider UPIN Number
    1H
    CHAMPUS Identification Number
    1J
    Facility ID Number
    D3
    National Council for Prescription Drug Programs Pharmacy Number
    G2
    Provider Commercial Number
    LU
    Location Number
    REF-02
    127
    Rendering Provider Secondary Identifier
    Required
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    DTM
    0500

    Claim Received Date

    OptionalMax use 1

    To specify pertinent dates and times

    Usage notes
    • Required whenever state or federal regulations or the provider contract mandate interest payment or prompt payment discounts based upon the receipt date of the claim by the payer. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
    Example
    DTM-01
    374
    Date Time Qualifier
    Required

    Code specifying type of date or time, or both date and time

    050
    Received
    DTM-02
    373
    Date
    Required
    CCYYMMDD format

    Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

    Usage notes
    • This is the date that the claim was received by the payer.
    DTM
    0500

    Coverage Expiration Date

    OptionalMax use 1

    To specify pertinent dates and times

    Usage notes
    • Required when payment is denied because of the expiration of coverage. If not required by this implementation guide, do not send.
    Example
    DTM-01
    374
    Date Time Qualifier
    Required

    Code specifying type of date or time, or both date and time

    036
    Expiration
    DTM-02
    373
    Date
    Required
    CCYYMMDD format

    Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

    Usage notes
    • This is the expiration date of the patient's coverage.
    DTM
    0500

    Statement From or To Date

    OptionalMax use 2

    To specify pertinent dates and times

    Usage notes
    • Dates at the claim level apply to the entire claim, including all service lines. Dates at the service line level apply only to the service line where they appear.
    • When claim dates are not provided, service dates are required for every service line.
    • When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines.
    • For retail pharmacy claims, the Claim Statement Period Start Date is equivalent to the prescription filled date.
    • Required when the "Statement From or To Dates" are not supplied at the service (2110 loop) level. If not required by this implementation guide, may be provided at senders discretion, but cannot be required by the receiver.
    • For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment.
    • When payment is being made in advance of services, the use of future dates is allowed.
    Example
    DTM-01
    374
    Date Time Qualifier
    Required

    Code specifying type of date or time, or both date and time

    232
    Claim Statement Period Start

    If the claim statement period start date is conveyed without a subsequent claim statement period end date, the end date is assumed to be the same as the start date. This date or code 233 is required when service level dates are not provided in the remittance advice.

    233
    Claim Statement Period End

    If a claim statement period end date is conveyed without a claim statement period start date, then the start date is assumed to be different from the end date but not conveyed at the payer's discretion. See the note on code 232.

    DTM-02
    373
    Claim Date
    Required
    CCYYMMDD format

    Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

    PER
    0600

    Claim Contact Information

    OptionalMax use 2

    To identify a person or office to whom administrative communications should be directed

    Usage notes
    • Required when there is a claim specific communications contact. If not required by this implementation guide, do not send.
    • When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800)555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number.
    Example
    If either Communication Number Qualifier (PER-05) or Claim Contact Communications Number (PER-06) is present, then the other is required
    If either Communication Number Qualifier (PER-07) or Communication Number Extension (PER-08) is present, then the other is required
    PER-01
    366
    Contact Function Code
    Required

    Code identifying the major duty or responsibility of the person or group named

    CX
    Payers Claim Office
    PER-02
    93
    Claim Contact Name
    Optional
    Min 1Max 60

    Free-form name

    PER-03
    365
    Communication Number Qualifier
    Required

    Code identifying the type of communication number

    EM
    Electronic Mail
    FX
    Facsimile
    TE
    Telephone
    PER-04
    364
    Claim Contact Communications Number
    Required
    Min 1Max 256

    Complete communications number including country or area code when applicable

    PER-05
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

    EM
    Electronic Mail
    EX
    Telephone Extension

    When used, the value following this code is the extension for the preceding communications contact number.

    FX
    Facsimile
    TE
    Telephone
    PER-06
    364
    Claim Contact Communications Number
    Optional
    Min 1Max 256

    Complete communications number including country or area code when applicable

    PER-07
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

    EX
    Telephone Extension
    PER-08
    364
    Communication Number Extension
    Optional
    Min 1Max 256

    Complete communications number including country or area code when applicable

    AMT
    0620

    Claim Supplemental Information

    OptionalMax use 13

    To indicate the total monetary amount

    Usage notes
    • Use this segment to convey information only. It is not part of the financial balancing of the 835.
    • Send/receive one AMT for each applicable non-zero value. Do not report any zero values.
    • Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send.
    Example
    AMT-01
    522
    Amount Qualifier Code
    Required

    Code to qualify amount

    AU
    Coverage Amount

    Use this monetary amount to report the total covered charges.

    This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan. This excludes charges considered not covered (i.e. per day television or telephone charges) but includes reductions to payments of covered services (i.e. reductions for amounts over fee schedule and patient deductibles).

    D8
    Discount Amount

    Prompt Pay Discount Amount

    See section 1.10.2.9 for additional information.

    DY
    Per Day Limit
    F5
    Patient Amount Paid

    Use this monetary amount for the amount the patient has already paid.

    I
    Interest

    See section 1.10.2.9 for additional information.

    NL
    Negative Ledger Balance

    Used only by Medicare Part A and Medicare Part B.

    T
    Tax
    T2
    Total Claim Before Taxes

    Used only when tax also applies to the claim.

    ZK
    Federal Medicare or Medicaid Payment Mandate - Category 1
    ZL
    Federal Medicare or Medicaid Payment Mandate - Category 2
    ZM
    Federal Medicare or Medicaid Payment Mandate - Category 3
    ZN
    Federal Medicare or Medicaid Payment Mandate - Category 4
    ZO
    Federal Medicare or Medicaid Payment Mandate - Category 5
    AMT-02
    782
    Claim Supplemental Information Amount
    Required
    Min 1Max 15

    Monetary amount

    Usage notes
    • Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements.
    QTY
    0640

    Claim Supplemental Information Quantity

    OptionalMax use 14

    To specify quantity information

    Usage notes
    • Use this segment to convey information only. It is not part of the financial balancing of the 835.
    • Send one QTY for each non-zero value. Do not report any zero values.
    • Required when the value of a specific quantity identified by the QTY01 qualifier is non-zero. If not required by this implementation guide, do not send.
    Example
    QTY-01
    673
    Quantity Qualifier
    Required

    Code specifying the type of quantity

    CA
    Covered - Actual
    CD
    Co-insured - Actual
    LA
    Life-time Reserve - Actual
    LE
    Life-time Reserve - Estimated
    NE
    Non-Covered - Estimated
    NR
    Not Replaced Blood Units
    OU
    Outlier Days
    PS
    Prescription
    VS
    Visits
    ZK
    Federal Medicare or Medicaid Payment Mandate - Category 1
    ZL
    Federal Medicare or Medicaid Payment Mandate - Category 2
    ZM
    Federal Medicare or Medicaid Payment Mandate - Category 3
    ZN
    Federal Medicare or Medicaid Payment Mandate - Category 4
    ZO
    Federal Medicare or Medicaid Payment Mandate - Category 5
    QTY-02
    380
    Claim Supplemental Information Quantity
    Required
    Min 1Max 15

    Numeric value of quantity

    2110 Service Payment Information Loop
    OptionalMax 999
    SVC
    0700

    Service Payment Information

    RequiredMax use 1

    To supply payment and control information to a provider for a particular service

    Usage notes
    • See section 1.10.2.1.1 (Service Line Balancing) for additional information.
    • The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO78*25~). See section 1.10.2.4.1 for additional information.
    • See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information.
    • Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send.
    Example
    SVC-01
    C003
    Composite Medical Procedure Identifier
    To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132).
    C003-01
    235
    Product or Service ID Qualifier
    Required

    Code identifying the type/source of the descriptive number used in Product/Service ID (234)

    • C003-01 qualifies C003-02 and C003-08.
    Usage notes
    • The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7.
    AD
    American Dental Association Codes
    ER
    Jurisdiction Specific Procedure and Supply Codes
    HC
    Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

    Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC.

    HP
    Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code

    Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System.

    IV
    Home Infusion EDI Coalition (HIEC) Product/Service Code

    This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property & Casualty claims/encounters that are not covered under HIPAA.

    N4
    National Drug Code in 5-4-2 Format
    N6
    National Health Related Item Code in 4-6 Format

    This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names National Health Related Item Code in 4-6 Format Codes as an allowable code set under HIPAA. 2) For Property & Casualty claims/encounters that are not covered under HIPAA.

    NU
    National Uniform Billing Committee (NUBC) UB92 Codes
    UI
    U.P.C. Consumer Package Code (1-5-5)

    This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names U.P.C. Consumer Package Code (1-5-5) Codes as an allowable code set under HIPAA. 2) For Property & Casualty claims/encounters that are not covered under HIPAA.

    WK
    Advanced Billing Concepts (ABC) Codes

    This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used in transactions covered under HIPAA by parties registered in the pilot project and their trading partners.

    C003-02
    234
    Adjudicated Procedure Code
    Required
    Min 1Max 48

    Identifying number for a product or service

    • If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
    Usage notes
    • This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1.
    C003-03
    1339
    Procedure Modifier
    Optional
    Min 2Max 2

    This identifies special circumstances related to the performance of the service, as defined by trading partners

    • C003-03 modifies the value in C003-02 and C003-08.
    C003-04
    1339
    Procedure Modifier
    Optional
    Min 2Max 2

    This identifies special circumstances related to the performance of the service, as defined by trading partners

    • C003-04 modifies the value in C003-02 and C003-08.
    C003-05
    1339
    Procedure Modifier
    Optional
    Min 2Max 2

    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
    Optional
    Min 2Max 2

    This identifies special circumstances related to the performance of the service, as defined by trading partners

    • C003-06 modifies the value in C003-02 and C003-08.
    SVC-02
    782
    Line Item Charge Amount
    Required
    Min 1Max 15

    Monetary amount

    • SVC02 is the submitted service charge.
    Usage notes
    • Use this monetary amount for the submitted service charge amount.
    • Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements.
    SVC-03
    782
    Line Item Provider Payment Amount
    Required
    Min 1Max 15

    Monetary amount

    • SVC03 is the amount paid this service.
    Usage notes
    • Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. See 1.10.2.1, Balancing, for additional information.
    SVC-04
    234
    National Uniform Billing Committee Revenue Code
    Optional
    Min 1Max 48

    Identifying number for a product or service

    • SVC04 is the National Uniform Billing Committee Revenue Code.
    Usage notes
    • If the original claim and adjudication only referenced an NUBC revenue code, that is supplied in SVC01 and this element is not used.
    SVC-05
    380
    Units of Service Paid Count
    Optional
    Min 1Max 15

    Numeric value of quantity

    • SVC05 is the paid units of service.
    Usage notes
    • If not present, the value is assumed to be one.
    SVC-06
    C003
    Composite Medical Procedure Identifier
    To identify a medical procedure by its standardized codes and applicable modifiers - SVC06 is the original submitted medical procedure.
    Usage notes

    Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send.

    C003-01
    235
    Product or Service ID Qualifier
    Required

    Code identifying the type/source of the descriptive number used in Product/Service ID (234)

    • C003-01 qualifies C003-02 and C003-08.
    Usage notes
    • The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7.
    AD
    American Dental Association Codes
    ER
    Jurisdiction Specific Procedure and Supply Codes
    HC
    Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

    Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC.

    HP
    Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code

    Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System.

    IV
    Home Infusion EDI Coalition (HIEC) Product/Service Code

    This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property & Casualty claims/encounters that are not covered under HIPAA.

    N4
    National Drug Code in 5-4-2 Format
    NU
    National Uniform Billing Committee (NUBC) UB92 Codes
    WK
    Advanced Billing Concepts (ABC) Codes

    This qualifier can only be used in transactions covere under HIPAA by parties registered in the pilot project and their trading partners.

    C003-02
    234
    Procedure Code
    Required
    Min 1Max 48

    Identifying number for a product or service

    • If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
    C003-03
    1339
    Procedure Modifier
    Optional
    Min 2Max 2

    This identifies special circumstances related to the performance of the service, as defined by trading partners

    • C003-03 modifies the value in C003-02 and C003-08.
    C003-04
    1339
    Procedure Modifier
    Optional
    Min 2Max 2

    This identifies special circumstances related to the performance of the service, as defined by trading partners

    • C003-04 modifies the value in C003-02 and C003-08.
    C003-05
    1339
    Procedure Modifier
    Optional
    Min 2Max 2

    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
    Optional
    Min 2Max 2

    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
    Optional
    Min 1Max 80

    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
    Optional
    Min 1Max 15

    Numeric value of quantity

    • SVC07 is the original submitted units of service.
    DTM
    0800

    Service Date

    OptionalMax use 2

    To specify pertinent dates and times

    Usage notes
    • Dates at the service line level apply only to the service line where they appear.
    • If used for inpatient claims and no service date was provided on the claim then report the through date from the claim level.
    • When claim dates are not provided, service dates are required for every service line.
    • When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines.
    • Required when claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
    • For retail pharmacy claims, the service date is equivalent to the prescription filled date.
    • For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment.
    • When payment is being made in advance of services, the use of future dates is allowed.
    Example
    DTM-01
    374
    Date Time Qualifier
    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
    Required
    CCYYMMDD format

    Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

    CAS
    0900

    Service Adjustment

    OptionalMax use 99

    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
    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
    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
    Required

    Code identifying the general category of payment adjustment

    Usage notes
    • Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.)
    CO
    Contractual Obligations

    Use this code when a joint payer/payee agreement or a regulatory requirement has resulted in an adjustment.

    OA
    Other adjustments

    Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13.

    PI
    Payor Initiated Reductions

    Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments).

    PR
    Patient Responsibility
    CAS-02
    1034
    Adjustment Reason Code
    Required
    Min 1Max 5

    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
    Required
    Min 1Max 15

    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
    Optional
    Min 1Max 15

    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
    Optional
    Min 1Max 5

    Code identifying the detailed reason the adjustment was made

    Usage notes
    • See CAS02.
    CAS-06
    782
    Adjustment Amount
    Optional
    Min 1Max 15

    Monetary amount

    • CAS06 is the amount of the adjustment.
    Usage notes
    • See CAS03.
    CAS-07
    380
    Adjustment Quantity
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CAS07 is the units of service being adjusted.
    Usage notes
    • See CAS04.
    CAS-08
    1034
    Adjustment Reason Code
    Optional
    Min 1Max 5

    Code identifying the detailed reason the adjustment was made

    Usage notes
    • See CAS02.
    CAS-09
    782
    Adjustment Amount
    Optional
    Min 1Max 15

    Monetary amount

    • CAS09 is the amount of the adjustment.
    Usage notes
    • See CAS03.
    CAS-10
    380
    Adjustment Quantity
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CAS10 is the units of service being adjusted.
    Usage notes
    • See CAS04.
    CAS-11
    1034
    Adjustment Reason Code
    Optional
    Min 1Max 5

    Code identifying the detailed reason the adjustment was made

    Usage notes
    • See CAS02.
    CAS-12
    782
    Adjustment Amount
    Optional
    Min 1Max 15

    Monetary amount

    • CAS12 is the amount of the adjustment.
    Usage notes
    • See CAS03.
    CAS-13
    380
    Adjustment Quantity
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CAS13 is the units of service being adjusted.
    Usage notes
    • See CAS04.
    CAS-14
    1034
    Adjustment Reason Code
    Optional
    Min 1Max 5

    Code identifying the detailed reason the adjustment was made

    Usage notes
    • See CAS02.
    CAS-15
    782
    Adjustment Amount
    Optional
    Min 1Max 15

    Monetary amount

    • CAS15 is the amount of the adjustment.
    Usage notes
    • See CAS03.
    CAS-16
    380
    Adjustment Quantity
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CAS16 is the units of service being adjusted.
    Usage notes
    • See CAS04.
    CAS-17
    1034
    Adjustment Reason Code
    Optional
    Min 1Max 5

    Code identifying the detailed reason the adjustment was made

    Usage notes
    • See CAS02.
    CAS-18
    782
    Adjustment Amount
    Optional
    Min 1Max 15

    Monetary amount

    • CAS18 is the amount of the adjustment.
    Usage notes
    • See CAS03.
    CAS-19
    380
    Adjustment Quantity
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CAS19 is the units of service being adjusted.
    Usage notes
    • See CAS04.
    REF
    1000

    HealthCare Policy Identification

    OptionalMax use 5

    To specify identifying information

    Usage notes
    • Required when;
    • The payment is adjusted in accordance with the Payer's published Healthcare Policy Code list and
    • A Claim Adjustment Reason Code identified by the notation, "refer to 835 Healthcare Policy identification segment", in the Claim Adjustment Reason Code List is present in a related CAS segment and
    • The payer has a published enumerated healthcare policy code list available to healthcare providers via an un-secure public website and
    • The payer wishes to supply this policy detail to reduce provider inquiries.

    If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

    • Healthcare Policy - A clinical/statutory rule use to determine claim adjudication that cannot be explained by the sole use of a claim adjustment reason code in the CAS segment and Remittance Advise Remark code when appropriate.
    • The term Healthcare Policy is intended to include Medical Review Policy, Dental Policy Review, Property and Casualty Policies, Workers Comp Policies and Pharmacy Policies for example Medicare LMRP's.( Local Medicare Review policies) and NCD (National Coverage Determinations).
    • This policy segment must not be used to provide a proprietary explanation code or reason for adjustment.
    • Supply the Healthcare policy identifier in REF02 as provided by the payer's published Healthcare policy code list. This policy code will be used to explain the policy used to process the claim which resulted in the adjusted payment.
    • If this segment is used, the PER (Payer Web Site) segment is required to provide an un-secure WEB contact point where the provider can access the payer's enumerated, published healthcare policy.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    0K
    Policy Form Identifying Number
    REF-02
    127
    Healthcare Policy Identification
    Required
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    REF
    1000

    Line Item Control Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • This is the Line Item Control Number submitted in the 837, which is utilized by the provider for tracking purposes. See section 1.10.2.11 and 1.10.2.14.1 for additional information on usage with split claims or services. Note - the value in REF02 can include alpha characters.
    • Required when a Line Item Control Number was received on the original claim or when claim or service line splitting has occurred. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    6R
    Provider Control Number
    REF-02
    127
    Line Item Control Number
    Required
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    REF
    1000

    Rendering Provider Information

    OptionalMax use 10

    To specify identifying information

    Usage notes
    • Required when the rendering provider for this service is different than the rendering provider applicable at the claim level. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    0B
    State License Number
    1A
    Blue Cross Provider Number
    1B
    Blue Shield Provider Number
    1C
    Medicare Provider Number
    1D
    Medicaid Provider Number
    1G
    Provider UPIN Number
    1H
    CHAMPUS Identification Number
    1J
    Facility ID Number
    D3
    National Council for Prescription Drug Programs Pharmacy Number
    G2
    Provider Commercial Number
    HPI
    Centers for Medicare and Medicaid Services National Provider Identifier

    This qualifier is REQUIRED when the National Provider Identifier is mandated for use and the provider is a covered health care provider under that mandate.

    SY
    Social Security Number
    TJ
    Federal Taxpayer's Identification Number
    REF-02
    127
    Rendering Provider Identifier
    Required
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    REF
    1000

    Service Identification

    OptionalMax use 8

    To specify identifying information

    Usage notes
    • Required when related service specific reference identifiers were used in the process of adjudicating this service. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    1S
    Ambulatory Patient Group (APG) Number
    APC
    Ambulatory Payment Classification
    BB
    Authorization Number
    E9
    Attachment Code
    G1
    Prior Authorization Number
    G3
    Predetermination of Benefits Identification Number
    LU
    Location Number

    This is the Payer's identification for the provider location. This is REQUIRED when the specific site of service affected the payment of the claim.

    RB
    Rate code number

    Rate Code Number reflects Ambulatory Surgical Center (ASC) rate for Medicare, either 0, 50, 100 or 150%.

    REF-02
    127
    Provider Identifier
    Required
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    AMT
    1100

    Service Supplemental Amount

    OptionalMax use 9

    To indicate the total monetary amount

    Usage notes
    • This segment is used to convey information only. It is not part of the financial balancing of the 835.
    • Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send.
    Example
    AMT-01
    522
    Amount Qualifier Code
    Required

    Code to qualify amount

    B6
    Allowed - Actual

    Allowed amount is the amount the payer deems payable prior to considering patient responsibility.

    KH
    Deduction Amount

    Late Filing Reduction

    T
    Tax
    T2
    Total Claim Before Taxes

    Use this monetary amount for the service charge before taxes. This is only used when there is an applicable tax amount on this service.

    ZK
    Federal Medicare or Medicaid Payment Mandate - Category 1
    ZL
    Federal Medicare or Medicaid Payment Mandate - Category 2
    ZM
    Federal Medicare or Medicaid Payment Mandate - Category 3
    ZN
    Federal Medicare or Medicaid Payment Mandate - Category 4
    ZO
    Federal Medicare or Medicaid Payment Mandate - Category 5
    AMT-02
    782
    Service Supplemental Amount
    Required
    Min 1Max 15

    Monetary amount

    Usage notes
    • Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements.
    QTY
    1200

    Service Supplemental Quantity

    OptionalMax use 6

    To specify quantity information

    Usage notes
    • Use this segment to convey information only. It is not part of the financial balancing of the 835.
    • Required when new Federal Medicare or Medicaid mandates require Quantity counts and value of specific quantities identified in the QTY01 qualifier are non-zero. If not required by this implementation guide, do not send.
    Example
    QTY-01
    673
    Quantity Qualifier
    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
    Required
    Min 1Max 15

    Numeric value of quantity

    LQ
    1300

    Health Care Remark Codes

    OptionalMax use 99

    To identify standard industry codes

    Usage notes
    • Use this segment to provide informational remarks only. This segment has no impact on the actual payment. Changes in claim payment amounts are provided in the CAS segments.
    • Required when remark codes or NCPDP Reject/Payment codes are necessary for the provider to fully understand the adjudication message for a given service line. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
    Example
    LQ-01
    1270
    Code List Qualifier Code
    Required

    Code identifying a specific industry code list

    HE
    Claim Payment Remark Codes
    RX
    National Council for Prescription Drug Programs Reject/Payment Codes
    LQ-02
    1271
    Remark Code
    Required
    Min 1Max 30

    Code indicating a code from a specific industry code list

    Summary

    PLB
    0100

    Provider Adjustment

    OptionalMax use >1

    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
    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
    PLB-01
    127
    Provider Identifier
    Required
    Min 1Max 50

    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
    Required
    CCYYMMDD format

    Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

    • PLB02 is the last day of the provider's fiscal year.
    Usage notes
    • 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.
    C042-01
    426
    Adjustment Reason Code
    Required

    Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment

    50
    Late Charge

    This is the Late Claim Filing Penalty or Medicare Late Cost Report Penalty.

    51
    Interest Penalty Charge

    This is the interest assessment for late filing.

    72
    Authorized Return

    This is the provider refund adjustment. This adjustment acknowledges a refund received from a provider for previous overpayment. PLB03-2 must always contain an identifying reference number when the value is used. PLB04 must contain a negative value. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset.

    90
    Early Payment Allowance
    AH
    Origination Fee

    This is the claim transmission fee. This is used for transmission fees that are not specific to or dependent upon individual claims.

    AM
    Applied to Borrower's Account

    See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. Use this code to identify the loan repayment amount.

    This is capitation specific.

    AP
    Acceleration of Benefits

    This is the accelerated payment amount or withholding. Withholding or payment identification is indicated by the sign of the amount in PLB04. A positive value represents a withholding. A negative value represents a payment.

    B2
    Rebate

    This adjustment code applies when a provider has remitted an overpayment to a health plan in excess of the amount requested by the health plan. The amount accepted by the health plan is reported using code 72 (Authorized Return) and offset by the amount with code WO (Overpayment Recovery). The excess returned by the provider is reported as a negative amount using code B2, returning the excess funds to the provider.

    B3
    Recovery Allowance

    This represents the check received from the provider for overpayments generated by payments from other payers. This code differs from the provider refund adjustment identified with code 72. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset.

    BD
    Bad Debt Adjustment

    This is the bad debt passthrough.

    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).

    C042-02
    127
    Provider Adjustment Identifier
    Optional
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    Usage notes
    • Use when necessary to assist the receiver in identifying, tracking or reconcilling the adjustment. See sections 1.10.2.10 (Capitation and Related Payments), 1.10.2.5 (Advanced Payments and Reconciliation) and 1.10.2.12 (Balance Forward Processing) for further information.
    PLB-04
    782
    Provider Adjustment Amount
    Required
    Min 1Max 15

    Monetary amount

    • PLB04 is the adjustment amount.
    Usage notes
    • This is the adjustment amount for the preceding adjustment reason.
    • Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements.
    PLB-05
    C042
    Adjustment Identifier
    To provide the category and identifying reference information for an adjustment - PLB05 is the adjustment information as defined by the payer.
    Usage notes

    Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send.

    C042-01
    426
    Adjustment Reason Code
    Required
    Min 2Max 2

    Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment

    C042-02
    127
    Provider Adjustment Identifier
    Optional
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    PLB-06
    782
    Provider Adjustment Amount
    Optional
    Min 1Max 15

    Monetary amount

    • PLB06 is the adjustment amount.
    Usage notes
    • This is the adjustment amount for the preceding adjustment reason.
    PLB-07
    C042
    Adjustment Identifier
    To provide the category and identifying reference information for an adjustment - PLB07 is adjustment information as defined by the payer.
    Usage notes

    Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send.

    C042-01
    426
    Adjustment Reason Code
    Required
    Min 2Max 2

    Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment

    C042-02
    127
    Provider Adjustment Identifier
    Optional
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    PLB-08
    782
    Provider Adjustment Amount
    Optional
    Min 1Max 15

    Monetary amount

    • PLB08 is the adjustment amount.
    Usage notes
    • This is the adjustment amount for the preceding adjustment reason.
    PLB-09
    C042
    Adjustment Identifier
    To provide the category and identifying reference information for an adjustment - PLB09 is adjustment information as defined by the payer.
    Usage notes

    Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send.

    C042-01
    426
    Adjustment Reason Code
    Required
    Min 2Max 2

    Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment

    C042-02
    127
    Provider Adjustment Identifier
    Optional
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    PLB-10
    782
    Provider Adjustment Amount
    Optional
    Min 1Max 15

    Monetary amount

    • PLB10 is the adjustment amount.
    Usage notes
    • This is the adjustment amount for the preceding adjustment reason.
    PLB-11
    C042
    Adjustment Identifier
    To provide the category and identifying reference information for an adjustment - PLB11 is adjustment information as defined by the payer.
    Usage notes

    Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send.

    C042-01
    426
    Adjustment Reason Code
    Required
    Min 2Max 2

    Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment

    C042-02
    127
    Provider Adjustment Identifier
    Optional
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    PLB-12
    782
    Provider Adjustment Amount
    Optional
    Min 1Max 15

    Monetary amount

    • PLB12 is the adjustment amount.
    Usage notes
    • This is the adjustment amount for the preceding adjustment reason.
    PLB-13
    C042
    Adjustment Identifier
    To provide the category and identifying reference information for an adjustment - PLB13 is adjustment information as defined by the payer.
    Usage notes

    Required when an additional adjustment not already reported applies to this remittance advice. If not required by this implementation guide, do not send.

    C042-01
    426
    Adjustment Reason Code
    Required
    Min 2Max 2

    Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment

    C042-02
    127
    Provider Adjustment Identifier
    Optional
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    PLB-14
    782
    Provider Adjustment Amount
    Optional
    Min 1Max 15

    Monetary amount

    • PLB14 is the adjustment amount.
    Usage notes
    • This is the adjustment amount for the preceding adjustment reason.
    SE
    0200

    Transaction Set Trailer

    RequiredMax use 1

    To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)

    Example
    SE-01
    96
    Transaction Segment Count
    Required
    Min 1Max 10

    Total number of segments included in a transaction set including ST and SE segments

    SE-02
    329
    Transaction Set Control Number
    Required
    Min 4Max 9

    Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

    Usage notes
    • The Transaction Set Control Numbers in ST02 and SE02 must be identical. The originator assigns the Transaction Set Control Number, which must be unique within a functional group (GS-GE). This unique number also aids in error resolution research.

    Functional Group Trailer

    RequiredMax use 1

    To indicate the end of a functional group and to provide control information

    Example
    GE-01
    97
    Number of Transaction Sets Included
    Required
    Min 1Max 6

    Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element

    GE-02
    28
    Group Control Number
    Required
    Min 1Max 9

    Assigned number originated and maintained by the sender

    Interchange Control Trailer

    RequiredMax use 1

    To define the end of an interchange of zero or more functional groups and interchange-related control segments

    Example
    IEA-01
    I16
    Number of Included Functional Groups
    Required
    Min 1Max 5

    A count of the number of functional groups included in an interchange

    IEA-02
    I12
    Interchange Control Number
    Required
    Min 9Max 9

    A control number assigned by the interchange sender

    EDI Samples

    Example 1: Dollars and Data Sent Separately

    ISA*00* *00* *ZZ*ABCPAYER *ZZ*ABCPAYER *190827*0212*^*00501*191511902*0*P*>~
    GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
    ST*835*112233~
    BPR*I*1100*C*ACH*CCP*01*888999777*DA*24681012*1935665544**01*111333555*DA*144444*20190316~
    TRN*1*71700666555*1935665544~
    DTM*405*20190314~
    N1*PR*RUSHMORE LIFE~
    N3*10 SOUTH AVENUET~
    N4*RAPID CITY*SD*55111~
    PER*BL*JOHN WAYNE*TE*8005551212*EX*123~
    N1*PE*ACME MEDICAL CENTER*XX*5544667733~
    REF*TJ*777667755~
    LX*1~
    CLP*5554555444*1*800*500*300*12*94060555410000*11*1~
    NM1*QC*1*BUDD*WILLIAM****MI*33344555510~
    AMT*AU*800~
    SVC*HC>99211*800*500~
    DTM*472*20190301~
    CAS*PR*1*300~
    AMT*B6*800~
    CLP*8765432112*1*1200*600*600*12*9407779923000*11*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

    ISA*00* *00* *ZZ*ABCPAYER *ZZ*ABCPAYER *190827*0212*^*00501*191511902*0*P*>~
    GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
    ST*835*35681~
    BPR*I*810.8*C*CHK************20190331~
    TRN*1*12345*1512345678~
    REF*EV*XYZ CLEARINGHOUSE~
    N1*PR*DENTAL OF ABC~
    N3*225 MAIN STREET~
    N4*CENTERVILLE*PA*17111~
    PER*BL*JANE DOE*TE*9005555555~
    N1*PE*BAN DDS LLC*XX*9999947036~
    REF*TJ*212121212~
    LX*1~
    CLP*7722337*1*226*132**12*119932404007801*11*1~
    NM1*QC*1*DOE*SANDY****MI*SJD11112~
    NM1*82*1*BAN*ERIN****XX*1811901945~
    AMT*AU*132~
    SVC*AD>D0120*46*25~
    DTM*472*20190324~
    CAS*CO*45*21~
    AMT*B6*25~
    SVC*AD>D0220*25*14~
    DTM*472*20190324~
    CAS*CO*45*11~
    AMT*B6*14~
    SVC*AD>D0230*22*10~
    DTM*472*20190324~
    CAS*CO*45*12~
    AMT*B6*10~
    SVC*AD>D0274*60*34~
    DTM*472*20190324~
    CAS*CO*45*26~
    AMT*B6*34~
    SVC*AD>D1110*73*49~
    DTM*472*20190324~
    CAS*CO*45*24~
    AMT*B6*49~
    CLP*7722337*1*119*74**12*119932404007801*11*1~
    NM1*QC*1*DOE*SALLY****MI*SJD11111~
    NM1*IL*1*DOE*JOHN****MI*SJD11111~
    NM1*82*1*BAN*ERIN****XX*1811901945~
    AMT*AU*74~
    SVC*AD>D0120*46*25~
    DTM*472*20190324~
    CAS*CO*45*21~
    AMT*B6*25~
    SVC*AD>D1110*73*49~
    DTM*472*20190324~
    CAS*CO*45*24~
    AMT*B6*49~
    CLP*7722337*1*226*108*24*12*119932404007801*11*1~
    NM1*QC*1*SMITH*SALLY****MI*SJD11113~
    NM1*82*1*BAN*ERIN****XX*1811901945~
    AMT*AU*132~
    SVC*AD>D0120*46*25~
    DTM*472*20190324~
    CAS*CO*45*21~
    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

    ISA*00* *00* *ZZ*ABCPAYER *ZZ*ABCPAYER *190827*0212*^*00501*191511902*0*P*>~
    GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
    ST*835*35681~
    BPR*I*132*C*CHK************20190331~
    TRN*1*12345*1512345678~
    REF*EV*CLEARINGHOUSE~
    N1*PR*DELTA DENTAL OF ABC~
    N3*225 MAIN STREET~
    N4*CENTERVILLE*PA*17111~
    PER*BL*JANE DOE*TE*9005555555~
    N1*PE*BAN DDS LLC*FI*999994703~
    LX*1~
    CLP*7722337*1*226*132**12*119932404007801~
    NM1*QC*1*DOE*SALLY****MI*SJD11111~
    NM1*82*1*BAN*ERIN****XX*1811901945~
    AMT*AU*132~
    SVC*AD>D0120*46*25~
    DTM*472*20190324~
    CAS*CO*131*21~
    AMT*B6*25~
    SVC*AD>D0220*25*14~
    DTM*472*20190324~
    CAS*CO*131*11~
    AMT*B6*14~
    SVC*AD>D0230*22*10~
    DTM*472*20190324~
    CAS*CO*131*12~
    AMT*B6*10~
    SVC*AD>D0274*60*34~
    DTM*472*20190324~
    CAS*CO*131*26~
    AMT*B6*34~
    SVC*AD>D1110*73*49~
    DTM*472*20190324~
    CAS*CO*131*24~
    AMT*B6*49~
    SE*34*35681~
    GE*1*12345678~
    IEA*1*191511902~

    Example 4: Claim Adjustment Reason Code 45

    ISA*00* *00* *ZZ*ABCPAYER *ZZ*ABCPAYER *190827*0212*^*00501*191511902*0*P*>~
    GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
    ST*835*10060875~
    BPR*I*80.00*C*CHK************20190816~
    TRN*1*CK NUMBER 1*1234567890~
    REF*EV*FAC~
    DTM*405*20190827~
    N1*PR*ANY PLAN USA~
    N3*1 WALK THIS WAY~
    N4*ANYCITY*OH*45209~
    PER*CX**TE*8661112222~
    PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
    PER*IC**UR*WWW.ANYPAYER.COM~
    N1*PE*PROVIDER*XX*1123454567~
    N3*2255 ANY ROAD~
    N4*ANY CITY*CA*12211~
    REF*TJ*123456789~
    LX*1~
    CLP*PATACCT*1*400*80**MC*CLAIMNUMBER*11*1~
    NM1*QC*1*DOE*JOHN*N***MI*ABC123456789~
    REF*1L*12345F~
    DTM*050*20190209~
    PER*CX*G CUSTOMER SERVICE DEPARTMENT*TE*8004074627~
    AMT*AU*150~
    SVC*HC>99213*150*80**1~
    DTM*472*20190101~
    CAS*CO*45*70~
    AMT*B6*80~
    SVC*HC>85003*100*0**1~
    DTM*472*20190101~
    CAS*CO*204*100~
    SVC*HC>36415*150*0**1~
    DTM*472*20190101~
    CAS*CO*97*150~
    SE*33*10060875~
    GE*1*12345678~
    IEA*1*191511902~

    Example 5a: Line Service Tax impacting payment only

    ISA*00* *00* *ZZ*ABCPAYER *ZZ*ABCPAYER *190827*0212*^*00501*191511902*0*P*>~
    GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
    ST*835*10060875~
    BPR*I*11.06*C*CHK************20190816~
    TRN*1*CK NUMBER 1*1234567890~
    REF*EV*FAC~
    DTM*405*20190827~
    N1*PR*ANY PLAN USA~
    N3*1 WALK THIS WAY~
    N4*ANYCITY*OH*45209~
    PER*CX**TE*8661112222~
    PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
    PER*IC**UR*WWW.ANYPAYER.COM~
    N1*PE*PROVIDER*XX*1123454567~
    N3*2255 ANY ROAD~
    N4*ANY CITY*CA*12211~
    REF*TJ*123456789~
    LX*1~
    CLP*PCN*1*36.20*11.06**12*CLAIMNUMB*11*1~
    NM1*QC*1*LAST*FIRST*J***MI*123456789~
    NM1*82*1******XX*1447481825~
    MOA***N25~
    REF*1L*102345~
    REF*EA*065789~
    DTM*050*20170113~
    AMT*AU*36.20~
    SVC*HC>99214*26.2*3.06~
    DTM*472*20170109~
    CAS*CO*45*23.2**137*-.06~
    REF*6R*B1~
    AMT*B6*3~
    SVC*HC>36415*10*8~
    DTM*472*20170109~
    CAS*CO*45*2~
    REF*6R*B2~
    AMT*B6*8~
    SE*35*10060875~
    GE*1*12345678~
    IEA*1*191511902~

    Example 5b: Line Service Bonuses impacting payment only

    ISA*00* *00* *ZZ*ABCPAYER *ZZ*ABCPAYER *190827*0212*^*00501*191511902*0*P*>~
    GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
    ST*835*10060875~
    BPR*I*12.00*C*CHK************20190816~
    TRN*1*CK NUMBER 1*1234567890~
    REF*EV*FAC~
    DTM*405*20190827~
    N1*PR*ANY PLAN USA~
    N3*1 WALK THIS WAY~
    N4*ANYCITY*OH*45209~
    PER*CX**TE*8661112222~
    PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
    PER*IC**UR*WWW.ANYPAYER.COM~
    N1*PE*PROVIDER*XX*1123454567~
    N3*2255 ANY ROAD~
    N4*ANY CITY*CA*12211~
    REF*TJ*123456789~
    LX*1~
    CLP*PCN*1*25*12*10*12*CLAIMNUMB*11*1~
    NM1*QC*1*LAST*FIRST*J***MI*123456789~
    NM1*82*1******XX*1447481825~
    MOA***N25~
    REF*1L*102345~
    REF*EA*065789~
    DTM*050*20170113~
    AMT*AU*25~
    SVC*HC>99214*25*12~
    DTM*472*20170109~
    CAS*CO*45*5**161*-2~
    CAS*PR*3*10~
    REF*6R*123~
    AMT*B6*20~
    SE*31*10060875~
    GE*1*12345678~
    IEA*1*191511902~

    Example 5c: Line Service Penalty impacting payment only

    ISA*00* *00* *ZZ*ABCPAYER *ZZ*ABCPAYER *190827*0212*^*00501*191511902*0*P*>~
    GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
    ST*835*10060875~
    BPR*I*8.00*C*CHK************20190816~
    TRN*1*CK NUMBER 1*1234567890~
    REF*EV*FAC~
    DTM*405*20190827~
    N1*PR*ANY PLAN USA~
    N3*1 WALK THIS WAY~
    N4*ANYCITY*OH*45209~
    PER*CX**TE*8661112222~
    PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
    PER*IC**UR*WWW.ANYPAYER.COM~
    N1*PE*PROVIDER*XX*1123454567~
    N3*2255 ANY ROAD~
    N4*ANY CITY*CA*12211~
    REF*TJ*123456789~
    LX*1~
    CLP*PCN*1*25*8*10*12*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

    ISA*00* *00* *ZZ*ABCPAYER *ZZ*ABCPAYER *190827*0212*^*00501*191511902*0*P*>~
    GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
    ST*835*10060875~
    BPR*I*8000.00*C*CHK************20190816~
    TRN*1*CK NUMBER 1*1234567890~
    REF*EV*FAC~
    DTM*405*20190827~
    N1*PR*ANY PLAN USA~
    N3*1 WALK THIS WAY~
    N4*ANYCITY*OH*45209~
    PER*CX**TE*8661112222~
    PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
    PER*IC**UR*WWW.ANYPAYER.COM~
    N1*PE*PROVIDER*XX*1123454567~
    N3*2255 ANY ROAD~
    N4*ANY CITY*CA*12211~
    REF*TJ*123456789~
    LX*1~
    CLP*PATACCT*1*40000*8000**MC*CLAIMNUMBER*11*1~
    CAS*CO*197*2000*1*45*30000~
    NM1*QC*1*DOE*JOHN*N***MI*ABC123456789~
    REF*1L*12345F~
    DTM*232*20190101~
    DTM*233*20190105~
    DTM*050*20190209~
    PER*CX*G CUSTOMER SERVICE DEPARTMENT*TE*8004001212~
    AMT*AU*38000~
    QTY*CA*4~
    SE*27*10060875~
    GE*1*12345678~
    IEA*1*191511902~

    Example 8a: Claim submitted with incorrect subscriber as patient and incorrect ID

    ISA*00* *00* *ZZ*ABCPAYER *ZZ*ABCPAYER *190827*0212*^*00501*191511902*0*P*>~
    GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
    ST*835*10060875~
    BPR*I*120.03*C*CHK************20190816~
    TRN*1*CK NUMBER 1*1234567890~
    REF*EV*FAC~
    DTM*405*20190827~
    N1*PR*ANY PLAN USA~
    N3*1 WALK THIS WAY~
    N4*ANYCITY*OH*45209~
    PER*CX**TE*8661112222~
    PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
    PER*IC**UR*WWW.ANYPAYER.COM~
    N1*PE*PROVIDER*XX*1123454567~
    N3*2255 ANY ROAD~
    N4*ANY CITY*CA*12211~
    REF*TJ*123456789~
    LX*1~
    CLP*04777796TLC777122*1*155*120.03**13*8838888212*11*1~
    NM1*QC*1*MASTERS*MARVIN*L****MI*80444444403~
    NM1*IL*1*CABLE*MABEL****MI*80444444403~
    NM1*74*1*MASTERS*MARVIN****C*80444444401~
    NM1*82*1*SHELTON MD*BLAKE****XX*1666666666~
    REF*1L*28~
    REF*CE*HSOAP-LAOA~
    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

    ISA*00* *00* *ZZ*ABCPAYER *ZZ*ABCPAYER *190827*0212*^*00501*191511902*0*P*>~
    GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
    ST*835*10060875~
    BPR*I*35.06*C*CHK************20190816~
    TRN*1*CK NUMBER 1*1234567890~
    REF*EV*FAC~
    DTM*405*20190827~
    N1*PR*ANY PLAN USA~
    N3*1 WALK THIS WAY~
    N4*ANYCITY*OH*45209~
    PER*CX**TE*8661112222~
    PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
    PER*IC**UR*WWW.ANYPAYER.COM~
    N1*PE*PROVIDER*XX*1123454567~
    N3*2255 ANY ROAD~
    N4*ANY CITY*CA*12211~
    REF*TJ*123456789~
    LX*1~
    CLP*02333TLC222222*1*115*35.06*35*13*8333333214*11*1~
    NM1*QC*1*KEATON*ALEX*P****MI*80000006006~
    NM1*IL*1*THOMAS*JASON****MI*80000006006~
    NM1*74*1**JEROME****C*80000006001~
    NM1*82*1*BLOOD MD*RED N****XX*1888888886~
    REF*1L*28~
    REF*CE*OAPOS-LAOA~
    DTM*232*20191113~
    DTM*233*20191113~
    DTM*050*20191119~
    AMT*AU*115~
    SVC*HC|99213*115*35.06**1~
    DTM*472*20191113~
    CAS*CO*45*44.94~
    CAS*PR*3*35~
    REF*LU*11~
    REF*6R*22261389~
    AMT*B6*70.06~
    SE*35*10060875~
    GE*1*12345678~
    IEA*1*191511902~

    Example 8c: Claim submitted with for subscriber missing the Middle initial

    ISA*00* *00* *ZZ*ABCPAYER *ZZ*ABCPAYER *190827*0212*^*00501*191511902*0*P*>~
    GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
    ST*835*10060875~
    BPR*I*2415.25*C*CHK************20190816~
    TRN*1*CK NUMBER 1*1234567890~
    REF*EV*FAC~
    DTM*405*20190827~
    N1*PR*ANY PLAN USA~
    N3*1 WALK THIS WAY~
    N4*ANYCITY*OH*45209~
    PER*CX**TE*8661112222~
    PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
    PER*IC**UR*WWW.ANYPAYER.COM~
    N1*PE*PROVIDER*XX*1123454567~
    N3*2255 ANY ROAD~
    N4*ANY CITY*CA*12211~
    REF*TJ*123456789~
    LX*1~
    CLP*05444444TLC999999*1*3903*2415.25**13*8777777782*21*1~
    NM1*QC*1*GONZALES*SAMMY****MI*80455555502~
    NM1*IL*1*LAPLANTE*FERN****MI*80455555502~
    NM1*74*1***R~
    NM1*82*1*GOOD MD*ROBERT B****XX*19999999987~
    REF*1L*28~
    REF*CE*OAPOS-LAOA~
    DTM*232*20191101~
    DTM*233*20191101~
    DTM*050*20191114~
    AMT*AU*3903~
    AMT*F5*150~
    SVC*HC>59400*3903*2415.25**1~
    DTM*472*20191101~
    CAS*CO*45*1487.75~
    REF*LU*21~
    REF*6R*22215592~
    AMT*B6*2415.25~
    SE*35*10060875~
    GE*1*12345678~
    IEA*1*191511902~

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