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Stedi maintains this guide based on public documentation from CGS Medicare. Contact CGS Medicare for official EDI specifications. To report any errors in this guide, please contact us. X12 835 Health Care Claim Payment/Advice (X221A1) X12 Release 5010 Revised November 17, 2023 Go to Stedi Network 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 View the latest version of this implementation guide as an interactive webpage https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice- x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 POWERED BY Build EDI implementation guides at stedi.com 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 1/125 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 Payer Identification Loop N1 0800 Payer Identification Max use 1 Required N3 1000 Payer Address Max use 1 Required N4 1100 Payer City, State, ZIP Code Max use 1 Required REF 1200 Additional Payer Identification Max use 4 Optional PER 1300 Payer Business Contact Information Max use 1 Optional PER 1300 Payer Technical Contact Information Max use 1 Required PER 1300 Payer WEB Site Max use 1 Optional Payee Identification Loop N1 0800 Payee Identification Max use 1 Required N3 1000 Payee Address Max use 1 Optional N4 1100 Payee City, State, ZIP Code Max use 1 Optional REF 1200 Payee Additional Identification Max use 1 Optional RDM 1400 Remittance Delivery Method Max use 1 Optional 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 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 2/125 Claim Payment Information Loop CLP 0100 Claim Payment Information Max use 1 Required CAS 0200 Claim Adjustment Max use 99 Optional NM1 0300 Corrected Patient/Insured Name Max use 1 Optional NM1 0300 Corrected Priority Payer Name Max use 1 Optional NM1 0300 Crossover Carrier Name Max use 1 Optional NM1 0300 Insured or Subscriber Max use 1 Optional NM1 0300 Other Subscriber Name Max use 1 Optional NM1 0300 Patient Name Max use 1 Required NM1 0300 Service Provider Name Max use 1 Optional MIA 0330 Inpatient Adjudication Information Max use 1 Optional MOA 0350 Outpatient Adjudication Information Max use 1 Optional REF 0400 Other Claim Related Identification Max use 5 Optional DTM 0500 Claim Received Date Max use 1 Optional DTM 0500 Coverage Expiration Date Max use 1 Optional DTM 0500 Statement From or To Date Max use 2 Optional PER 0600 Claim Contact Information Max use 2 Optional AMT 0620 Claim Supplemental Information Max use 13 Optional QTY 0640 Claim Supplemental Information Quantity Max use 14 Optional Service Payment Information Loop SVC 0700 Service Payment Information Max use 1 Required DTM 0800 Service Date Max use 2 Optional CAS 0900 Service Adjustment Max use 99 Optional REF 1000 HealthCare Policy Identification Max use 5 Optional REF 1000 Line Item Control Number Max use 1 Optional REF 1000 Rendering Provider Information Max use 10 Optional REF 1000 Service Identification Max use 8 Optional AMT 1100 Service Supplemental Amount Max use 9 Optional QTY 1200 Service Supplemental Quantity Max use 6 Optional LQ 1300 Health Care Remark Codes Max use 99 Optional Summary 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 3/125 PLB 0100 Provider Adjustment Max use 1 Optional SE 0200 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 4/125 ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange- related control segments Example ISA00 00 XXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXX2501301107^0050100000000 0XX>~ Max use 1 Required ISA-01 I01 Authorization Information Qualifier Identifier (ID) 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 Min 10 Max 10 String (AN) Required 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 Identifier (ID) 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 Min 10 Max 10 String (AN) Required 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 Min 2 Max 2 Identifier (ID) Required 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 Min 15 Max 15 String (AN) Required 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 Min 2 Max 2 Identifier (ID) Required 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 5/125 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 Min 15 Max 15 String (AN) Required 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 YYMMDD format Date (DT) Required Date of the interchange ISA-10 I09 Interchange Time HHMM format Time (TM) Required Time of the interchange ISA-11 I65 Repetition Separator Min 1 Max 1 String (AN) Required 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 Identifier (ID) 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 Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender ISA-14 I13 Acknowledgment Requested Min 1 Max 1 Identifier (ID) Required 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 Min 1 Max 1 Identifier (ID) Required Code indicating whether data enclosed by this interchange envelope is test, production or information I Information 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 6/125 P Production Data T Test Data ISA-16 I15 Component Element Separator Min 1 Max 1 String (AN) Required 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 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 7/125 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GSHPXXXXXXXXXXXXXX20250130101100X005010X2 21A1~ Max use 1 Required GS-01 479 Functional Identifier Code Identifier (ID) Required Code identifying a group of application related transaction sets HP Health Care Claim Payment/Advice (835) GS-02 142 Application Sender's Code Min 2 Max 15 String (AN) Required Code identifying party sending transmission; codes agreed to by trading partners GS-03 124 Application Receiver's Code Min 2 Max 15 String (AN) Required Code identifying party receiving transmission; codes agreed to by trading partners GS-04 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year GS-05 337 Time HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time (TM) Required 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 Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required 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 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 8/125 GS-08 480 Version / Release / Industry Identifier Code String (AN) 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 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 9/125 Heading ST 0100 Heading > ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST8350001~ Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) 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 Min 4 Max 9 Numeric (N) Required 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. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 10/125 BPR 0200 Heading > BPR Financial Information To indicate the beginning of a Payment Order/Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and/or information from payer to payee to occur 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 BPRI00CACHCTX01XXXXXXDAXXXXXXXXXXXXXXX XXXXXXX01XXXXXXSGXXX20250130~ If either Depository Financial Institution (DFI) Identification Number Qualifier	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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 Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required 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 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 8/125 GS-08 480 Version / Release / Industry Identifier Code String (AN) 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 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 9/125 Heading ST 0100 Heading > ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST8350001~ Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) 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 Min 4 Max 9 Numeric (N) Required 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. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 10/125 BPR 0200 Heading > BPR Financial Information To indicate the beginning of a Payment Order/Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and/or information from payer to payee to occur 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 BPRI00CACHCTX01XXXXXXDAXXXXXXXXXXXXXXX XXXXXXX01XXXXXXSGXXX20250130~ 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 Max use 1 Required BPR-01 305 Transaction Handling Code Identifier (ID) 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. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 11/125 BPR-02 782 Total Actual Provider Payment Amount Min 1 Max 15 Decimal number (R) Required 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 Identifier (ID) 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. BPR-04 591 Payment Method Code Identifier (ID) 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. CHK Check Use this code to indicate that a check has been issued for payment. 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 Identifier (ID) 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 Identifier (ID) Code identifying the type of identification number of Depository Financial Institution (DFI) 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 12/125 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. BPR-07 507 Sender DFI Identifier Min 3 Max 12 String (AN) Optional 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 Identifier (ID) 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 Min 1 Max 35 String (AN) Optional 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 Min 10 Max 10 String (AN) Optional 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 Min 9 Max 9 String (AN) Optional 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 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 13/125 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 Identifier (ID) 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. BPR-13 507 Receiver or Provider Bank ID Number Min 3 Max 12 String (AN) Optional 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 Identifier (ID) 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 Min 1 Max 35 String (AN) Optional 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 CCYYMMDD format Date (DT) Required 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). 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 14/125 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. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 15/125 TRN 0400 Heading > TRN Reassociation Trace Number 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 TRN1XXXXXXXXXXXXXXXXX~ Max use 1 Required TRN-01 481 Trace Type Code Identifier (ID) Required Code identifying which transaction is being referenced 1 Current Transaction Trace Numbers TRN-02 127 Check or EFT Trace Number Min 1 Max 50	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
the transfer instructions Usage notes 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 13/125 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 Identifier (ID) 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. BPR-13 507 Receiver or Provider Bank ID Number Min 3 Max 12 String (AN) Optional 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 Identifier (ID) 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 Min 1 Max 35 String (AN) Optional 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 CCYYMMDD format Date (DT) Required 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). 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 14/125 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. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 15/125 TRN 0400 Heading > TRN Reassociation Trace Number 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 TRN1XXXXXXXXXXXXXXXXX~ Max use 1 Required TRN-01 481 Trace Type Code Identifier (ID) Required Code identifying which transaction is being referenced 1 Current Transaction Trace Numbers TRN-02 127 Check or EFT Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 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 Min 10 Max 10 String (AN) Required 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 Min 1 Max 50 String (AN) Optional 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 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 16/125 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. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 17/125 CUR 0500 Heading > CUR Foreign Currency Information 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 CURPRXXX~ Max use 1 Optional CUR-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer CUR-02 100 Currency Code Min 3 Max 3 Identifier (ID) Required Code (Standard ISO) for country in whose currency the charges are specified Usage notes This is the currency code for the payment currency. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 18/125 REF 0600 Heading > REF Receiver Identification 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 REFEVXX~ Variants (all may be used) REF Version Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EV Receiver Identification Number REF-02 127 Receiver Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 19/125 REF 0600 Heading > REF Version Identification 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 REFF2XX~ Variants (all may be used) REF Receiver Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F2 Version Code - Local REF-02 127 Version Identification Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 20/125 DTM 0700 Heading > DTM Production Date 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 DTM40520250130~ Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 405 Production DTM-02 373 Production Date CCYYMMDD format Date (DT) Required 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. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 21/125 1000A Payer Identification Loop Max 1 Required Variants (all may be used) Payee Identification Loop N1 0800 Heading > Payer Identification Loop > N1 Payer Identification 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 N1PRXXXXXVXXXXX~ If either Identification Code Qualifier (N1-03) or Payer Identifier (N1-04) is present, then the other is required Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer N1-02 93 Payer Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) 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 Min 2 Max 80 String (AN) Optional 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. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 22/125 N3 1000 Heading > Payer Identification Loop > N3 Payer Address To specify the location of the named party Example N3XXXXXXX~ Max use 1 Required N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 23/125 N4 1100 Heading > Payer Identification Loop > N4 Payer City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXXXX~ 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 Max use 1 Required N4-01 19 Payer City Name Min 2 Max 30 String (AN) Required 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 Min 2 Max 2 Identifier (ID) Optional 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 Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 24/125 REF 1200 Heading > Payer Identification Loop > REF Additional Payer Identification 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 REF2UXXXXX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number For Medicare carriers or intermediaries,	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
name N1-03 66 Identification Code Qualifier Identifier (ID) 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 Min 2 Max 80 String (AN) Optional 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. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 22/125 N3 1000 Heading > Payer Identification Loop > N3 Payer Address To specify the location of the named party Example N3XXXXXXX~ Max use 1 Required N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 23/125 N4 1100 Heading > Payer Identification Loop > N4 Payer City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXXXX~ 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 Max use 1 Required N4-01 19 Payer City Name Min 2 Max 30 String (AN) Required 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 Min 2 Max 2 Identifier (ID) Optional 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 Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 24/125 REF 1200 Heading > Payer Identification Loop > REF Additional Payer Identification 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 REF2UXXXXX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) 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. REF-02 127 Additional Payer Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes CGS reference ID 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 25/125 PER 1300 Heading > Payer Identification Loop > PER Payer Business Contact Information 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 PERCXXXFXXXXXXFXXXXXEXXXXXX~ Variants (all may be used) PER Payer Technical Contact Information PER Payer WEB Site 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 Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Payer Contact Name Min 1 Max 60 String (AN) Optional 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 Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 26/125 PER-04 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail 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 Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 27/125 PER 1300 Heading > Payer Identification Loop > PER Payer Technical Contact Information 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 PERBLXXURXXXXFXXXXXXXEMXX~ Variants (all may be used) PER Payer Business Contact Information PER Payer WEB Site 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 Max use >1 Required PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named BL Technical Department PER-02 93 Payer Technical Contact Name Min 1 Max 60 String (AN) Optional 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 Identifier (ID) 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 Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 28/125 PER-05 365 Communication Number Qualifier Identifier (ID) 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 Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number 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 Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 29/125 1000A Payer Identification Loop end PER 1300 Heading > Payer Identification Loop > PER Payer WEB Site 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 PERICURXXXXX~ Variants (all may be used) PER Payer Business Contact Information PER Payer Technical Contact Information Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number UR Uniform Resource Locator (URL) PER-04 364 Communication Number Min 1 Max 256 String (AN) Required 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. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 30/125 1000B Payee Identification Loop Max 1 Required Variants (all may be used) Payer Identification Loop N1 0800 Heading > Payee Identification Loop > N1 Payee Identification 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 N1PEXXXXXXX~ Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PE Payee N1-02 93 Payee Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) 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 Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 31/125 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. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 32/125 N3 1000 Heading > Payee Identification Loop > N3 Payee Address 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 N3XXXXXXXXX~ Max use	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
this implementation guide, do not send. This is a direct link to the policy location of the un-secure website. Example PERICURXXXXX~ Variants (all may be used) PER Payer Business Contact Information PER Payer Technical Contact Information Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number UR Uniform Resource Locator (URL) PER-04 364 Communication Number Min 1 Max 256 String (AN) Required 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. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 30/125 1000B Payee Identification Loop Max 1 Required Variants (all may be used) Payer Identification Loop N1 0800 Heading > Payee Identification Loop > N1 Payee Identification 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 N1PEXXXXXXX~ Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PE Payee N1-02 93 Payee Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) 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 Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 31/125 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. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 32/125 N3 1000 Heading > Payee Identification Loop > N3 Payee Address 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 N3XXXXXXXXX~ Max use 1 Optional N3-01 166 Payee Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payee Address Line Min 1 Max 55 String (AN) Optional Address information 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 33/125 N4 1100 Heading > Payee Identification Loop > N4 Payee City, State, ZIP Code 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 N4XXXXXXXXXXXXX~ 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 Max use 1 Optional N4-01 19 Payee City Name Min 2 Max 30 String (AN) Required 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 Min 2 Max 2 Identifier (ID) Optional 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 Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 34/125 REF 1200 Heading > Payee Identification Loop > REF Payee Additional Identification 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 REFD3XXXXX~ Max use >1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) 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 Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 35/125 RDM 1400 Heading > Payee Identification Loop > RDM Remittance Delivery Method 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 RDMBMXXX~ Max use 1 Optional RDM-01 756 Report Transmission Code Identifier (ID) 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 Min 1 Max 60 String (AN) Optional 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 Min 1 Max 256 String (AN) Optional 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 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 36/125 1000B Payee Identification Loop end Heading end Contains URL web address or e-mail address. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 37/125 Detail 2000 Header Number Loop Max >1 Optional LX 0030 Detail > Header Number Loop > LX Header Number 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 LX0~ Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set Usage notes Medicare will send “1” for Assigned or “0” for NonAssigned. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 38/125 TS3 0050 Detail > Header Number Loop > TS3 Provider Summary Information 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 TS3XX202501300000000000000*****0000000000 00000000000000*0000000000000000*00000000000 00000000000000000000000*00~ Max use 1 Optional TS3-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TS301 is the provider number. Usage notes This is the provider number. TS3-02 1331 Facility Type Code Min 1 Max 2 String (AN) Required 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 CCYYMMDD format Date (DT) Required 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 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 39/125 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 Min 1 Max 15 Decimal number (R) Required 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 Min 1 Max 15 Decimal number (R) Required 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS315 is the summary of non-lab charges. Usage notes See TR3 note 3. TS3-17 782	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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 TS3XX202501300000000000000*****0000000000 00000000000000*0000000000000000*00000000000 0000000000000000000000000~ Max use 1 Optional TS3-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TS301 is the provider number. Usage notes This is the provider number. TS3-02 1331 Facility Type Code Min 1 Max 2 String (AN) Required 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 CCYYMMDD format Date (DT) Required 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 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 39/125 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 Min 1 Max 15 Decimal number (R) Required 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 Min 1 Max 15 Decimal number (R) Required 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS315 is the summary of non-lab charges. Usage notes See TR3 note 3. TS3-17 782 Total HCPCS Reported Charge Amount Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 40/125 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS322 is the total patient reimbursement. Usage notes See TR3 note 3. TS3-23 380 Total PIP Claim Count Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS324 is total periodic interim payment (PIP) adjustment. Usage notes 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 41/125 See TR3 note 3. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 42/125 TS2 0070 Detail > Header Number Loop > TS2 Provider Supplemental Summary Information 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 TS20000000000000000000000000000000000000000 00000000000000000000000000000000000000000000 0000000000000000000000000000000000000000000 000000000000000~ Max use 1 Optional TS2-01 782 Total DRG Amount Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS202 is the total federal specific amount. Usage notes See TR3 note 2. TS2-03 782 Total Hospital Specific Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS203 is the total hospital specific amount. Usage notes See TR3 note 2. TS2-04 782 Total Disproportionate Share Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS204 is the total disproportionate share amount. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 43/125 Usage notes See TR3 note 2. TS2-05 782 Total Capital Amount Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS206 is the total indirect medical education amount. Usage notes See TR3 note 2. TS2-07 380 Total Outlier Day Count Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS208 is the total day outlier amount. Usage notes See TR3 note 2. TS2-09 782 Total Cost Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS209 is the total cost outlier amount. Usage notes See TR3 note 2. TS2-10 380 Average DRG Length of Stay Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 44/125 TS210 is the diagnosis related group (DRG) average length of stay. Usage notes See TR3 note 2. TS2-11 380 Total Discharge Count Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 45/125 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS219 is the total prospective payment system (PPS) disproportionate share, hospital diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 46/125 2100 Claim Payment Information Loop Max >1 Required CLP 0100 Detail > Header Number Loop > Claim Payment Information Loop > CLP Claim Payment Information 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 CLPXXX2000000000000000000000000012XXXX XXXXX0*0~ Max use 1 Required CLP-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required 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 Identifier (ID) 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) 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 47/125 When this code is used, the Crossover Carrier Name NM1 segment is required. 21 Processed as Tertiary, Forwarded to Additional Payer(s)	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS219 is the total prospective payment system (PPS) disproportionate share, hospital diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 46/125 2100 Claim Payment Information Loop Max >1 Required CLP 0100 Detail > Header Number Loop > Claim Payment Information Loop > CLP Claim Payment Information 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 CLPXXX2000000000000000000000000012XXXX XXXXX00~ Max use 1 Required CLP-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required 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 Identifier (ID) 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) 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 47/125 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. CLP-03 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required 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 Min 1 Max 15 Decimal number (R) Required Monetary amount CLP04 is the amount paid this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. See section 1.10.2.9 for information about interest considerations. Use this monetary amount for the amount paid for this claim. It can be positive, zero or negative, but the value in BPR02 may not be negative. CLP-05 782 Patient Responsibility Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CLP05 is the patient responsibility amount. Usage notes Amounts in CLP05 must have supporting adjustments reflected in CAS segments at the 2100 (CLP) or 2110 (SVC) loop level with a Claim Adjustment Group (CAS01) code of PR (Patient Responsibility). Use this monetary amount for the payer's statement of the patient responsibility amount for this claim, which can include such items as deductible, non-covered services, co-pay and co-insurance. This is not used for reversals. See section 1.10.2.8, Reversals and Corrections, for additional information. CLP-06 1032 Claim Filing Indicator Code Identifier (ID) Required 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 48/125 Code identifying type of claim Usage notes For many providers to electronically post the 835 remittance data to their patient accounting systems without human intervention, a unique, provider-specific insurance plan code is needed. This code allows the provider to separately identify and manage the different product lines or contractual arrangements between the payer and the provider. Because most payers maintain the same Originating Company Identifier in the TRN03 or BPR10 for all product lines or contractual relationships, the CLP06 is used by the provider as a table pointer in combination with the TRN03 or BPR10 to identify the unique, provider-specific insurance plan code needed to post the payment without human intervention. The value should mirror the value received in the original claim (2- 005 SBR09 of the 837), if applicable, or provide the value as assigned or edited by the payer. For example the BL from the SBR09 in the 837 would be returned as 12, 13, 15, in the 835 when more details are known. The 837 SBR09 code CI (Commercial Insurance) is generic, if through adjudication the specific type of plan is obtained a more specific code must be returned in the 835. The 837 and 835 transaction code lists for this element are not identical by design. There are some business differences between the two transactions. When a code from the 837 is not available in the 835 another valid code from the 835 must be assigned by the payer. Medicare will send “MB” for Part B and DME. Medicare will send “MA” for Part A. 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) MA Medicare Part A MB Medicare Part B MC Medicaid CLP-07 127 Payer Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CLP07 is the payer's internal control number. Usage notes Use this number for the payer's internal control number. This number must apply to the entire claim. CLP-08 1331 Facility Type Code Min 1 Max 2 String (AN) Optional Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. Usage notes Since professional or dental claims can have different place of service codes for services within a single claim, default to the place of service of the first service line when the service lines are not all for the same place of service. This number was received in CLM05-1 of the 837 claim. CLP-09 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 49/125 Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type Usage notes This number was received in CLM05-3 of the 837 Claim. CLP-11 1354 Diagnosis Related Group (DRG) Code Min 1 Max 4 Identifier (ID) Optional Code indicating a patient's diagnosis group based on a patient's illness, diseases, and medical problems CLP-12 380 Diagnosis Related Group (DRG) Weight Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CLP12 is the diagnosis-related group (DRG) weight. Usage notes This is the adjudicated DRG Weight. CLP-13 954 Discharge Fraction Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%) CLP13 is the discharge fraction. Usage notes This is the adjudicated discharge fraction. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 50/125 CAS 0200 Detail > Header Number Loop > Claim Payment Information Loop > CAS Claim Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Payers must use this CAS segment to report claim level adjustments that cause the amount paid to differ from the amount originally charged. See 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. See the SVC TR3 Note #1 for details about per diem adjustments. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment must be the first non-zero adjustment and is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Required when dollar amounts and/or quantities are being adjusted at the claim level. If not required by this implementation guide, do not send. Example CASOAXX00000000000X000000000000000XXXX00 0000000000000XXXXX00000000000000XXXX0000000 00000000000XX0000000000000000000~ If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS- 07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 51/125 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR,	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
for a particular service within the claim being paid Usage notes Payers must use this CAS segment to report claim level adjustments that cause the amount paid to differ from the amount originally charged. See 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. See the SVC TR3 Note #1 for details about per diem adjustments. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment must be the first non-zero adjustment and is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Required when dollar amounts and/or quantities are being adjusted at the claim level. If not required by this implementation guide, do not send. Example CASOAXX00000000000X000000000000000XXXX00 0000000000000XXXXX00000000000000XXXX0000000 00000000000XX0000000000000000000~ If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS- 07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 51/125 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer/payee contractual agreement or a regulatory requirement resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the claim level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes See section 1.10.2.4.1 for additional information. A positive value decreases the covered days, and a negative number increases the covered days. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 52/125 CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 53/125 Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. Usage notes See CAS03. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 54/125 CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 55/125 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Corrected Patient/Insured Name To supply the full name of an individual or organizational entity Usage notes Since the patient is always the insured for Medicare and Medicaid, this segment always provides corrected patient information for Medicare and Medicaid. For other carriers, this will always be the corrected insured information. Required when needed to provide corrected information about the patient or insured. If not required by this implementation guide, do not send. Example NM1741XXXXXXXXXXXXX*XXXCXX~ Variants (all may be used) NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Corrected Insured Identification Indicator (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 74 Corrected Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Corrected Patient or Insured Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Corrected Patient or Insured First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Corrected Patient or Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 56/125 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Corrected Patient or Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) C Insured's Changed Unique Identification Number NM1-09 67 Corrected Insured Identification Indicator Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 57/125 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Corrected Priority Payer Name To supply the full name of an individual or organizational entity Usage notes Provide any reference numbers in NM109. Use of this segment identifies the priority payer. Do not use this segment when the Crossover Carrier NM1 segment is used. Required when current payer believes that another payer has priority for making a payment and the claim is not being automatically transferred to that payer. If not required by this implementation guide, do not send. Example NM1PR2XX****XVXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Crossover Carrier Name NM1 Insured or Subscriber NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Corrected Priority Payer Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) AD Blue Cross Blue Shield Association Plan Code FI Federal Taxpayer's Identification Number NI National Association of Insurance Commissioners (NAIC) Identification This is the preferred ID unless XV is used. PI Payor Identification PP Pharmacy Processor Number XV Centers for Medicare and Medicaid Services PlanID 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 58/125 Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used. NM1-09 67 Corrected Priority Payer Identification Number Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 59/125 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Crossover Carrier Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the crossover carrier. Provide any reference numbers in NM109. The crossover carrier is defined as any payer to which the claim is transferred for further payment after being finalized by the current payer. Required when the claim is transferred to another carrier or coverage (CLP02 equals 19, 20, 21 or 23). If not required by this implementation guide, do not send. Example NM1TT2X***PIXXXXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Insured or Subscriber NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual TT Transfer To NM1-02 1065 Entity Type Qualifier Identifier (ID)	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 57/125 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Corrected Priority Payer Name To supply the full name of an individual or organizational entity Usage notes Provide any reference numbers in NM109. Use of this segment identifies the priority payer. Do not use this segment when the Crossover Carrier NM1 segment is used. Required when current payer believes that another payer has priority for making a payment and the claim is not being automatically transferred to that payer. If not required by this implementation guide, do not send. Example NM1PR2XX***XVXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Crossover Carrier Name NM1 Insured or Subscriber NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Corrected Priority Payer Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) AD Blue Cross Blue Shield Association Plan Code FI Federal Taxpayer's Identification Number NI National Association of Insurance Commissioners (NAIC) Identification This is the preferred ID unless XV is used. PI Payor Identification PP Pharmacy Processor Number XV Centers for Medicare and Medicaid Services PlanID 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 58/125 Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used. NM1-09 67 Corrected Priority Payer Identification Number Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 59/125 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Crossover Carrier Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the crossover carrier. Provide any reference numbers in NM109. The crossover carrier is defined as any payer to which the claim is transferred for further payment after being finalized by the current payer. Required when the claim is transferred to another carrier or coverage (CLP02 equals 19, 20, 21 or 23). If not required by this implementation guide, do not send. Example NM1TT2X***PIXXXXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Insured or Subscriber NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual TT Transfer To NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Crossover Carrier Name Min 1 Max 60 String (AN) Required Individual last name or organizational name Usage notes Name of the crossover carrier associated with this claim. NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 60/125 PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used. NM1-09 67 Crossover Carrier Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 61/125 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Insured or Subscriber To supply the full name of an individual or organizational entity Example NM1ILXXXXXXXXX***XXXXXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Corrected Priority Payer Identification Number (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Min 1 Max 1 Identifier (ID) Optional Code qualifying the type of entity NM102 qualifies NM103. NM1-03 1035 Corrected Priority Payer Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Name First Min 1 Max 35 String (AN) Optional Individual first name NM1-08 66 Identification Code Qualifier Min 1 Max 2 Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) NM1-09 67 Corrected Priority Payer Identification Number Min 2 Max 80 String (AN) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 62/125 Code identifying a party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 63/125 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes This is the name and ID number of the other subscriber when a corrected priority payer has been identified. When used, either the name or ID must be supplied. Required when a corrected priority payer has been identified in another NM1 segment AND the name or ID of the other subscriber is known. If not required by this implementation guide, do not send. Example NM1GB2XXXXXXXXXXXXXMIXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber NM1 Patient Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Other Subscriber Identifier (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual GB Other Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Subscriber Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name Usage notes At least one of NM103 or NM109 must be present. NM1-04 1036 Other Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 64/125 Individual middle name or initial Usage notes When only one character is present this is assumed to be the middle initial. NM1-07 1039 Other Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Not Used when NM102=1. II Standard Unique Health Identifier for each Individual in the United States Use this code if mandated in a final Federal Rule. MI Member Identification Number Use this code when supplying the number used for identification of the subscriber in NM109. NM1-09 67 Other Subscriber Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes At least one of NM103 or NM109 must be present. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 65/125 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Patient Name To supply the full name of an individual or organizational entity Usage notes Provide the patient's identification number in NM109. This segment must provide the information from the original claim. For example, when the claim is submitted as an ASC X12 837 transaction, this is the 2010CA loop NM1 Patient Name Segment unless not present on the original claim, then it is the 2010BA loop NM1 Subscriber name segment. The Corrected Patient/Insured Name NM1 segment identifies the adjudicated Insured Name and ID information if different than what was submitted on the claim. Example NM1QC1XXXXXXXXXXXXXX*XXMIXXXXXXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber NM1 Other Subscriber Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Patient Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual QC Patient NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Patient Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Patient First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Patient Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 66/125 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Patient Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes An example of this is when a Junior and Senior are covered under the same subscriber. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) MI Member Identification Number NM1-09 67 Patient Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code NM1-10 706 Entity Relationship Code Min 2 Max 2 Identifier (ID) Optional Code describing entity relationship NM110 and NM111 further define the type of entity in NM101. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 67/125 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Service Provider Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the rendering provider. An identification number is provided in NM109. This information is provided to facilitate identification of the claim within a payee's system. Other providers (e.g., Referring provider, supervising provider) related to the claim but not directly related to the payment are not supported and are not necessary for claim identification. Required when the rendering provider is different from the payee. If not required by this implementation guide, do not send. Example NM1822XXXXXXXXXXXXXXXXXXXX*XXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber NM1 Other Subscriber Name NM1 Patient Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 68/125 Individual middle name or initial Usage notes If this data element is used and contains only one character, it represents the middle initial. NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Patient First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Patient Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 66/125 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Patient Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes An example of this is when a Junior and Senior are covered under the same subscriber. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) MI Member Identification Number NM1-09 67 Patient Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code NM1-10 706 Entity Relationship Code Min 2 Max 2 Identifier (ID) Optional Code describing entity relationship NM110 and NM111 further define the type of entity in NM101. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 67/125 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Service Provider Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the rendering provider. An identification number is provided in NM109. This information is provided to facilitate identification of the claim within a payee's system. 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 NM1822XXXXXXXXXXXXXXXXXXXXXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber NM1 Other Subscriber Name NM1 Patient Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 68/125 Individual middle name or initial Usage notes If this data element is used and contains only one character, it represents the middle initial. NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) BD Blue Cross Provider Number BS Blue Shield Provider Number FI Federal Taxpayer's Identification Number This is the preferred ID until the National Provider ID is mandated and applicable. For individual providers as payees, use this qualifier to represent the Social Security Number. MC Medicaid Provider Number PC Provider Commercial Number SL State License Number UP Unique Physician Identification Number (UPIN) XX Centers for Medicare and Medicaid Services National Provider Identifier Required value if the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate. Otherwise, one of the other listed codes may be used. NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 69/125 MIA 0330 Detail > Header Number Loop > Claim Payment Information Loop > MIA Inpatient Adjudication Information To provide claim-level data related to the adjudication of Medicare inpatient claims Usage notes When used outside of the Medicare and Medicaid community only MIA01, 05, 20, 21, 22 and 23 may be used. Either MIA or MOA may appear, but not both. This segment must not be used for covered days or lifetime reserve days. For covered or lifetime reserve days, use the Supplemental Claim Information Quantities Segment in the Claim Payment Loop. All situational quantities and/or monetary amounts in this segment are required when the value of the item is different than zero. Required for all inpatient claims when there is a need to report Remittance Advice Remark Codes at the claim level or, the claim is paid by Medicare or Medicaid under the Prospective Payment System (PPS). If not required by this implementation guide, do not send. Example MIA0000000000000000000000000000XXXXXX00000 000000000000000000000000000000000000000 0000000000000000000000000000000000000000000 0XXXXXXXXXXX0000000000~ Max use 1 Optional MIA-01 380 Covered Days or Visits Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity MIA01 is the covered days. Usage notes Implementers utilizing the MIA segment always transmit the number zero. See the QTY segment at the claim level for covered days or visits count. MIA-02 782 PPS Operating Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA02 is the Prospective Payment System (PPS) Operating Outlier amount. Usage notes See TR3 note 4. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MIA-03 380 Lifetime Psychiatric Days Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA03 is the lifetime psychiatric days. MIA-04 782 Claim DRG Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 70/125 Monetary amount MIA04 is the Diagnosis Related Group (DRG) amount. MIA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA05 is the Claim Payment Remark Code. See Code Source 411. MIA-06 782 Claim Disproportionate Share Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA06 is the disproportionate share amount. MIA-07 782 Claim MSP Pass-through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA07 is the Medicare Secondary Payer (MSP) pass-through amount. MIA-08 782 Claim PPS Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA08 is the total Prospective Payment System (PPS) capital amount. MIA-09 782 PPS-Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 71/125 Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA19 is the professional component amount billed but not payable. MIA-20 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 72/125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA20 is the Claim Payment Remark Code. See Code Source 411. MIA-21 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA21 is the Claim Payment Remark Code. See Code Source 411. MIA-22 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 73/125 MOA 0350 Detail > Header Number Loop > Claim Payment Information Loop > MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required for outpatient/professional claims where there is a need to report a Remittance Advice Remark Code at the claim level or when the payer is Medicare or Medicaid and MOA01, 02, 08 or 09 are non-zero. If not required by this implementation guide, do not send. Either MIA or MOA may appear, but not both. All situational quantities and/or monetary amounts in this segment are;required when the value of the item is different than zero. Example MOA00000000000000XXXXXXXXXXXXXXXXXXXXX000 000000000000000000000~ Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%) MOA01 is the reimbursement rate. MOA-02 782 Claim HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 74/125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 73/125 MOA 0350 Detail > Header Number Loop > Claim Payment Information Loop > MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required for outpatient/professional claims where there is a need to report a Remittance Advice Remark Code at the claim level or when the payer is Medicare or Medicaid and MOA01, 02, 08 or 09 are non-zero. If not required by this implementation guide, do not send. Either MIA or MOA may appear, but not both. All situational quantities and/or monetary amounts in this segment are;required when the value of the item is different than zero. Example MOA00000000000000XXXXXXXXXXXXXXXXXXXXX000 000000000000000000000~ Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%) MOA01 is the reimbursement rate. MOA-02 782 Claim HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 74/125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 Claim ESRD Payment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 75/125 REF 0400 Detail > Header Number Loop > Claim Payment Information Loop > REF Other Claim Related Identification To specify identifying information Usage notes Required when additional reference numbers specific to the claim in the CLP segment are provided to identify information used in the process of adjudicating this claim. If not required by this implementation guide, do not send. Example REFCEXXX~ Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1L Group or Policy Number 6P Group Number This is the Other Insured Group Number. This is required when a Corrected Priority Payer is identified in the NM1 segment and the Group Number of the other insured for that payer is known. 28 Employee Identification Number CE Class of Contract Code EA Medical Record Identification Number F8 Original Reference Number When this is a correction claim and CLP07 does not equal the CLP07 value from the original claim payment, one iteration of this REF segment using this qualifier is REQUIRED to identify the original claim CLP07 value in REF02. See section 1.10.2.8, Reversals and Corrections, for additional information. TJ Federal Taxpayer's Identification Number REF-02 127 Other Claim Related Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 76/125 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Claim Received Date To specify pertinent dates and times Usage notes Required whenever state or federal regulations or the provider contract mandate interest payment or prompt payment discounts based upon the receipt date of the claim by the payer. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example DTM05020250130~ Variants (all may be used) DTM Coverage Expiration Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the date that the claim was received by the payer. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 77/125 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Coverage Expiration Date To specify pertinent dates and times Usage notes Required when payment is denied because of the expiration of coverage. If not required by this implementation guide, do not send. Example DTM03620250130~ Variants (all may be used) DTM Claim Received Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 036 Expiration DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the expiration date of the patient's coverage. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 78/125 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Statement From or To Date To specify pertinent dates and times Usage notes Dates at the claim level apply to the entire claim, including all service lines. Dates at the service line level apply only to the service line where they appear. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. For retail pharmacy claims, the Claim Statement Period Start Date is equivalent to the prescription filled date. Required when the "Statement From or To Dates" are not supplied at the service (2110 loop) level. If not required by this implementation guide, may be provided at senders discretion, but cannot be required by the receiver. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM23220250130~ Variants (all may be used) DTM Claim Received Date DTM Coverage Expiration Date Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 232 Claim Statement Period Start If the claim statement period start date is conveyed without a subsequent claim statement period end date, the end date is assumed to be the same as the start date. This date or code 233 is required when service level dates are not provided in the remittance advice. 233 Claim Statement Period End If a claim statement period end date is conveyed without a claim statement period start date, then the start date is assumed to be different from the end date but not conveyed at the payer's discretion. See the note on code 232. DTM-02 373 Claim Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 79/125 PER 0600 Detail > Header Number Loop > Claim Payment Information Loop > PER Claim Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when there is a claim specific communications contact. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800)555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number. Example PERCXXXXEMXXXXXXEXXXXXXEXXXX~ If either Communication Number Qualifier (PER-05) or Claim Contact Communications Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number Extension (PER-08) is present, then the other is required Max use 2 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Claim Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 80/125 EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Communication Number Extension Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 81/125 AMT 0620 Detail > Header Number Loop > Claim Payment Information Loop > AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. 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 AMTZL*00000~ Max use 13 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount AU	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
- Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 79/125 PER 0600 Detail > Header Number Loop > Claim Payment Information Loop > PER Claim Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when there is a claim specific communications contact. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800)555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number. Example PERCXXXXEMXXXXXXEXXXXXXEXXXX~ If either Communication Number Qualifier (PER-05) or Claim Contact Communications Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number Extension (PER-08) is present, then the other is required Max use 2 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Claim Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 80/125 EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Communication Number Extension Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 81/125 AMT 0620 Detail > Header Number Loop > Claim Payment Information Loop > AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send/receive one AMT for each applicable non-zero value. Do not report any zero values. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTZL00000~ Max use 13 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount AU Coverage Amount Use this monetary amount to report the total covered charges. This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan. This excludes charges considered not covered (i.e. per day television or telephone charges) but includes reductions to payments of covered services (i.e. reductions for amounts over fee schedule and patient deductibles). DY Per Day Limit F5 Patient Amount Paid Use this monetary amount for the amount the patient has already paid. I Interest See section 1.10.2.9 for additional information. NL Negative Ledger Balance Used only by Medicare Part A and Medicare Part B. ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 AMT-02 782 Claim Supplemental Information Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 82/125 QTY 0640 Detail > Header Number Loop > Claim Payment Information Loop > QTY Claim Supplemental Information Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send one QTY for each non-zero value. Do not report any zero values. Required when the value of a specific quantity identified by the QTY01 qualifier is non- zero. If not required by this implementation guide, do not send. Example QTYLA0000~ Max use 14 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity CA Covered - Actual CD Co-insured - Actual LA Life-time Reserve - Actual OU Outlier Days ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Claim Supplemental Information Quantity Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 83/125 2110 Service Payment Information Loop Max 999 Optional SVC 0700 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > SVC Service Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO7825~). See section 1.10.2.4.1 for additional information. See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information. Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send. Example SVCHP>XX>XX>XX>XX>XX0000000000000000XXXXX000 000000000000HC>XXXXXX>XX>XX>XX>XX>X0000000000~ Max use 1 Required SVC-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132). Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 84/125 AD American Dental Association Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes C003-02 234 Adjudicated Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. SVC-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC02 is the submitted service charge. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 85/125 Usage notes Use this monetary amount for the submitted service charge amount. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. SVC-03 782 Line Item Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC03 is the amount paid this service. Usage notes Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. See 1.10.2.1, Balancing, for additional information. SVC-04 234 National Uniform Billing Committee Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service SVC04 is the National Uniform Billing Committee Revenue Code. Usage notes If the original claim and adjudication only referenced an NUBC revenue code, that is supplied in SVC01 and this element is not used. SVC-05 380 Units of Service Paid Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC05 is the paid units of service. Usage notes If not present, the value is assumed to be one. SVC-06 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC06 is the original submitted medical procedure. Usage notes Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send. Max use 1 Optional C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 86/125 HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
in C003-02 and C003-08. SVC-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC02 is the submitted service charge. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 85/125 Usage notes Use this monetary amount for the submitted service charge amount. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. SVC-03 782 Line Item Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC03 is the amount paid this service. Usage notes Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. See 1.10.2.1, Balancing, for additional information. SVC-04 234 National Uniform Billing Committee Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service SVC04 is the National Uniform Billing Committee Revenue Code. Usage notes If the original claim and adjudication only referenced an NUBC revenue code, that is supplied in SVC01 and this element is not used. SVC-05 380 Units of Service Paid Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC05 is the paid units of service. Usage notes If not present, the value is assumed to be one. SVC-06 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC06 is the original submitted medical procedure. Usage notes Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send. Max use 1 Optional C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 86/125 HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVC-07 380 Original Units of Service Count Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 87/125 Numeric value of quantity SVC07 is the original submitted units of service. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 88/125 DTM 0800 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > DTM Service Date To specify pertinent dates and times Usage notes Dates at the service line level apply only to the service line where they appear. If used for inpatient claims and no service date was provided on the claim then report the through date from the claim level. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. Required when claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. For retail pharmacy claims, the service date is equivalent to the prescription filled date. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM15120250130~ Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 150 Service Period Start This qualifier is required for reporting the beginning of multi-day services. If not required by this implementation guide, do not send. 151 Service Period End This qualifier is required for reporting the end of multi-day services. If not required by this implementation guide, do not send. 472 Service This qualifier is required to indicate a single day service. If not required by this implementation guide, do not send. DTM-02 373 Service Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 89/125 CAS 0900 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > CAS Service Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes An example of this level of CAS is the reduction for the part of the service charge that exceeds the usual and customary charge for the service. See sections 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02). If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CASOAXXXXX0000000000000XX00000000000000000 00XXX0000000000000000000000000X000000000000 0000000000000000XX000000000000000000000000XX XX0*00000~ If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS- 07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 90/125 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer/payee agreement or a regulatory requirement has resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03 and CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes A positive number decreases paid units, and a negative value increases paid units. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 91/125 Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 90/125 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer/payee agreement or a regulatory requirement has resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03 and CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes A positive number decreases paid units, and a negative value increases paid units. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 91/125 Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 92/125 See CAS02. CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 93/125 CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 94/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF HealthCare Policy Identification To specify identifying information Usage notes Required when; The payment is adjusted in accordance with the Payer's published Healthcare Policy Code list and A Claim Adjustment Reason Code identified by the notation, "refer to 835 Healthcare Policy identification segment", in the Claim Adjustment Reason Code List is present in a related CAS segment and The payer has a published enumerated healthcare policy code list available to healthcare providers via an un-secure public website and The payer wishes to supply this policy detail to reduce provider inquiries. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Healthcare Policy - A clinical/statutory rule use to determine claim adjudication that cannot be explained by the sole use of a claim adjustment reason code in the CAS segment and Remittance Advise Remark code when appropriate. The term Healthcare Policy is intended to include Medical Review Policy, Dental Policy Review, Property and Casualty Policies, Workers Comp Policies and Pharmacy Policies for example Medicare LMRP's.( Local Medicare Review policies) and NCD (National Coverage Determinations). This policy segment must not be used to provide a proprietary explanation code or reason for adjustment. Supply the Healthcare policy identifier in REF02 as provided by the payer's published Healthcare policy code list. This policy code will be used to explain the policy used to process the claim which resulted in the adjusted payment. If this segment is used, the PER (Payer Web Site) segment is required to provide an un- secure WEB contact point where the provider can access the payer's enumerated, published healthcare policy. Example REF0KXX~ Variants (all may be used) REF Line Item Control Number REF Rendering Provider Information REF Service Identification Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0K Policy Form Identifying Number REF-02 127 Healthcare Policy Identification Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 95/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Line Item Control Number To specify identifying information Usage notes This is the Line Item Control Number submitted in the 837, which is utilized by the provider for tracking purposes. See section 1.10.2.11 and 1.10.2.14.1 for additional information on usage with split claims or services. Note - the value in REF02 can include alpha characters. Required when a Line Item Control Number was received on the original claim or when claim or service line splitting has occurred. If not required by this implementation guide, do not send. Example REF6RXXXX~ Variants (all may be used) REF HealthCare Policy Identification REF Rendering Provider Information REF Service Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 96/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Rendering Provider Information To specify identifying information Usage notes Required when the rendering provider for this service is different than the rendering provider applicable at the claim level. If not required by this implementation guide, do not send. Example REFHPIXXXXXX~ Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Service Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1C Medicare Provider Number HPI Centers for Medicare and Medicaid Services National Provider Identifier This qualifier is REQUIRED when the National Provider Identifier is mandated for use and the provider is a covered health care provider under that mandate. SY Social Security Number TJ Federal Taxpayer's Identification Number REF-02 127 Rendering Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 97/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Service Identification To specify identifying information Usage notes Required when related service specific reference identifiers were used in the process of adjudicating this service. If not required by this implementation guide, do not send. Example REFRBX~ Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Rendering Provider Information Max use 8 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1S Ambulatory Patient Group (APG) Number APC Ambulatory Payment Classification LU Location Number This is the Payer's identification for the provider location. This is REQUIRED when the specific site of service affected the payment of the claim. RB Rate code number Rate Code Number reflects Ambulatory Surgical Center (ASC) rate for Medicare, either 0, 50, 100 or 150%. REF-02 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 98/125 AMT 1100 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > AMT Service Supplemental Amount To indicate the total monetary amount Usage notes This segment is used to convey information only. It is not part of the financial balancing of the 835. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTZM00000000~ Max use 9 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount B6 Allowed - Actual Allowed amount is the amount the payer deems payable prior to considering patient responsibility. KH Deduction Amount Late Filing Reduction ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 AMT-02 782 Service Supplemental Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 99/125 QTY 1200 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > QTY Service Supplemental Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Required when new Federal Medicare or Medicaid mandates require Quantity counts and value of specific quantities identified in the QTY01 qualifier are non-zero. If not required by this implementation guide, do not send. Example QTYZO00000000000~ Max	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 97/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Service Identification To specify identifying information Usage notes Required when related service specific reference identifiers were used in the process of adjudicating this service. If not required by this implementation guide, do not send. Example REFRBX~ Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Rendering Provider Information Max use 8 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1S Ambulatory Patient Group (APG) Number APC Ambulatory Payment Classification LU Location Number This is the Payer's identification for the provider location. This is REQUIRED when the specific site of service affected the payment of the claim. RB Rate code number Rate Code Number reflects Ambulatory Surgical Center (ASC) rate for Medicare, either 0, 50, 100 or 150%. REF-02 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 98/125 AMT 1100 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > AMT Service Supplemental Amount To indicate the total monetary amount Usage notes This segment is used to convey information only. It is not part of the financial balancing of the 835. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTZM00000000~ Max use 9 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount B6 Allowed - Actual Allowed amount is the amount the payer deems payable prior to considering patient responsibility. KH Deduction Amount Late Filing Reduction ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 AMT-02 782 Service Supplemental Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 99/125 QTY 1200 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > QTY Service Supplemental Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Required when new Federal Medicare or Medicaid mandates require Quantity counts and value of specific quantities identified in the QTY01 qualifier are non-zero. If not required by this implementation guide, do not send. Example QTYZO00000000000~ Max use 6 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Service Supplemental Quantity Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 100/125 2110 Service Payment Information Loop end 2100 Claim Payment Information Loop end 2000 Header Number Loop end Detail end LQ 1300 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > LQ Health Care Remark Codes To identify standard industry codes Usage notes Use this segment to provide informational remarks only. This segment has no impact on the actual payment. Changes in claim payment amounts are provided in the CAS segments. Required when remark codes or NCPDP Reject/Payment codes are necessary for the provider to fully understand the adjudication message for a given service line. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example LQHEXXX~ Max use 99 Optional LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list HE Claim Payment Remark Codes LQ-02 1271 Remark Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 101/125 Summary PLB 0100 Summary > PLB Provider Adjustment To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service Usage notes These adjustments can either decrease the payment (a positive number) or increase the payment (a negative number). Zero dollar adjustments are not allowed. Some examples of PLB adjustments are a Periodic Interim Payment (loans and loan repayment) or a capitation payment. Multiple adjustments can be placed in one PLB segment, grouped by the provider identified in PLB01 and the period identified in PLB02. Although the PLB reference numbers are not standardized, refer to 1.10.2.9 (Interest and Prompt Payment Discounts), 1.10.2.10 (Capitation and Related Payments or Adjustments), 1.10.2.12 (Balance Forward Processing), 1.10.2.16 (Post Payment Recovery) and 1.10.2.17 (Claim Overpayment Recovery) for code suggestions and usage guidelines. The codes and notations under PLB03 and its components apply equally to PLB05, 07, 09, 11 and 13. Required when reporting adjustments to the actual payment that are NOT specific to a particular claim or service. If not required by this implementation guide, do not send. Example PLBXXXX20250130IS>XXXX0000000000XX>XXX00000 0000XX>X0000000XX>XXXX000000000000000XX>XXXX X0000XX>XXXXXX000000000000000~ If either Adjustment Identifier (PLB-05) or Provider Adjustment Amount (PLB-06) is present, then the other is required If either Adjustment Identifier (PLB-07) or Provider Adjustment Amount (PLB-08) is present, then the other is required If either Adjustment Identifier (PLB-09) or Provider Adjustment Amount (PLB-10) is present, then the other is required If either Adjustment Identifier (PLB-11) or Provider Adjustment Amount (PLB-12) is present, then the other is required If either Adjustment Identifier (PLB-13) or Provider Adjustment Amount (PLB-14) is present, then the other is required Max use >1 Optional PLB-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB01 is the provider number assigned by the payer. Usage notes When the National Provider Identifier (NPI) is mandated and the provider is a covered health care provider under that mandate, this must be the NPI assigned to the provider. Until the NPI is mandated, this is the provider identifier as assigned by the payer. PLB-02 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 102/125 year PLB02 is the last day of the provider's fiscal year. Usage notes This is the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known by the payer, use December 31st of the current year. PLB-03 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB03 is the adjustment information as defined by the payer. Max use 1 Required C042-01 426 Adjustment Reason Code Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment 50 Late Charge This is the Late Claim Filing Penalty or Medicare Late Cost Report Penalty. 51 Interest Penalty Charge This is the interest assessment for late filing. 72 Authorized Return This is the provider refund adjustment. This adjustment acknowledges a refund received from a provider for previous overpayment. PLB03-2 must always contain an identifying reference number when the value is used. PLB04 must contain a negative value. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. 90 Early Payment Allowance AP Acceleration of Benefits This is the accelerated payment amount or withholding. Withholding or payment identification is indicated by the sign of the amount in PLB04. A positive value represents a withholding. A negative value represents a payment. B2 Rebate This adjustment code applies when a provider has remitted an overpayment to a health plan in excess of the amount requested by the health plan. The amount accepted by the health plan is reported using code 72 (Authorized Return) and offset by the amount with code WO (Overpayment Recovery). The excess returned by the provider is reported as a negative amount using code B2, returning the excess funds to the provider. B3 Recovery Allowance This represents the check received from the provider for overpayments generated by payments from other payers. This code differs from the provider refund adjustment identified with code 72. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. BD Bad Debt Adjustment This is the bad debt passthrough. BN Bonus This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. C5 Temporary Allowance This is the tentative adjustment. CS Adjustment Provide supporting identification information in PLB03-2. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 103/125 CV Capital Passthru DM Direct Medical Education Passthru E3 Withholding See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. FB Forwarding Balance This is the balance forward. A negative value in PLB04 represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice. A reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information. GO Graduate Medical Education Passthru HM Hemophilia Clotting Factor Supplement IP Incentive Premium Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. 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	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
from the provider for overpayments generated by payments from other payers. This code differs from the provider refund adjustment identified with code 72. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. BD Bad Debt Adjustment This is the bad debt passthrough. BN Bonus This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. C5 Temporary Allowance This is the tentative adjustment. CS Adjustment Provide supporting identification information in PLB03-2. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 103/125 CV Capital Passthru DM Direct Medical Education Passthru E3 Withholding See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. FB Forwarding Balance This is the balance forward. A negative value in PLB04 represents a balance moving forward to a future payment advice. A positive value represents a balance being applied from a previous payment advice. A reference number must be supplied in PLB03-2 for tracking purposes. See 1.10.2.12, Balance Forward Processing, for further information. GO Graduate Medical Education Passthru HM Hemophilia Clotting Factor Supplement IP Incentive Premium Payment This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. IR Internal Revenue Service Withholding IS Interim Settlement This is the interim rate lump sum adjustment. J1 Nonreimbursable This offsets the claim or service level data that reflects what could be paid if not for demonstration program or other limitation that prevents issuance of payment. 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 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 104/125 TL Third Party Liability This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. WO Overpayment Recovery This is the recovery of previous overpayment. An identifying number must be provided in PLB03-2. See the notes on codes 72 and B3 for additional information about balancing against a provider refund. WU Unspecified Recovery Medicare is currently using this code to represent penalty collections withheld for the IRS (an outside source). C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional 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 Min 1 Max 15 Decimal number (R) Required 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. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 105/125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-06 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 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. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-08 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 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. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 106/125 Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-10 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 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. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-12 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 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 Max use 1 Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 107/125 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 Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-14 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB14 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 108/125 Summary end SE 0200 Summary > SE Transaction Set Trailer To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments) Example SE0000000001~ Max use 1 Required SE-01 96 Transaction Segment Count Min 1 Max 10 Numeric (N0) Required Total number of segments included in a transaction set including ST and SE segments SE-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required 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. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 109/125 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE000000000~ Max use 1 Required GE-01 97 Number of Transaction Sets Included Min 1 Max 6 Numeric (N0) Required 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 Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 110/125 IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA0000000000000~ Max use 1 Required IEA-01 I16 Number of Included Functional Groups Min 1 Max 5 Numeric (N0) Required A count of the number of functional groups included in an interchange IEA-02 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 111/125 EDI Samples Example 1: Dollars and Data Sent Separately ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST835112233~ BPRI1100CACHCCP01888999777DA246810121935665544*01111333555DA14444420190316~ TRN1717006665551935665544~ DTM40520190314~ N1PRRUSHMORE LIFE~ N310 SOUTH AVENUET~ N4RAPID CITYSD55111~ PERBLJOHN WAYNETE8005551212EX123~ N1PEACME MEDICAL CENTERXX5544667733~ REFTJ777667755~ LX1~ CLP555455544418005003001294060555410000111~ NM1QC1BUDDWILLIAM***MI33344555510~ AMTAU800~ SVCHC>99211800500~ DTM47220190301~ CASPR1300~ AMTB6800~ CLP876543211211200600600129407779923000111~ NM1QC1SETTLESUSAN**MI44455666610~ AMTAU1200~ SVCHC>935551200600~ DTM47220190310~ CASPR1600~ AMTB61200~ SE26112233~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 112/125 Example 2: Multiple Claims Single Check ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83535681~ BPRI810.8CCHK***********20190331~ TRN1123451512345678~ REFEVXYZ CLEARINGHOUSE~ N1PRDENTAL OF ABC~ N3225 MAIN STREET~ N4CENTERVILLEPA17111~ PERBLJANE DOETE9005555555~ N1PEBAN DDS LLCXX9999947036~ REFTJ212121212~ LX1~ CLP7722337122613212119932404007801111~ NM1QC1DOESANDY***MISJD11112~ NM1821BANERIN***XX1811901945~ AMTAU132~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D02202514~ DTM47220190324~ CASCO4511~ AMTB614~ SVCAD>D02302210~ DTM47220190324~ CASCO4512~ AMTB610~ SVCAD>D02746034~ DTM47220190324~ CASCO4526~ AMTB634~ SVCAD>D11107349~ DTM47220190324~ CASCO4524~ AMTB649~ CLP7722337111974*12119932404007801111~ NM1QC1DOESALLY***MISJD11111~ NM1IL1DOEJOHN***MISJD11111~ NM1821BANERIN***XX1811901945~ AMTAU74~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D11107349~ DTM47220190324~ CASCO4524~ AMTB649~ CLP772233712261082412119932404007801111~ NM1QC1SMITHSALLY**MISJD11113~ NM1821BANERIN***XX1811901945~ AMTAU132~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ 1/29/25, 8:52	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
adjustment amount for the preceding adjustment reason. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 108/125 Summary end SE 0200 Summary > SE Transaction Set Trailer To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments) Example SE0000000001~ Max use 1 Required SE-01 96 Transaction Segment Count Min 1 Max 10 Numeric (N0) Required Total number of segments included in a transaction set including ST and SE segments SE-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required 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. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 109/125 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE000000000~ Max use 1 Required GE-01 97 Number of Transaction Sets Included Min 1 Max 6 Numeric (N0) Required 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 Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 110/125 IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA0000000000000~ Max use 1 Required IEA-01 I16 Number of Included Functional Groups Min 1 Max 5 Numeric (N0) Required A count of the number of functional groups included in an interchange IEA-02 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 111/125 EDI Samples Example 1: Dollars and Data Sent Separately ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST835112233~ BPRI1100CACHCCP01888999777DA246810121935665544*01111333555DA14444420190316~ TRN1717006665551935665544~ DTM40520190314~ N1PRRUSHMORE LIFE~ N310 SOUTH AVENUET~ N4RAPID CITYSD55111~ PERBLJOHN WAYNETE8005551212EX123~ N1PEACME MEDICAL CENTERXX5544667733~ REFTJ777667755~ LX1~ CLP555455544418005003001294060555410000111~ NM1QC1BUDDWILLIAM***MI33344555510~ AMTAU800~ SVCHC>99211800500~ DTM47220190301~ CASPR1300~ AMTB6800~ CLP876543211211200600600129407779923000111~ NM1QC1SETTLESUSAN**MI44455666610~ AMTAU1200~ SVCHC>935551200600~ DTM47220190310~ CASPR1600~ AMTB61200~ SE26112233~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 112/125 Example 2: Multiple Claims Single Check ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83535681~ BPRI810.8CCHK***********20190331~ TRN1123451512345678~ REFEVXYZ CLEARINGHOUSE~ N1PRDENTAL OF ABC~ N3225 MAIN STREET~ N4CENTERVILLEPA17111~ PERBLJANE DOETE9005555555~ N1PEBAN DDS LLCXX9999947036~ REFTJ212121212~ LX1~ CLP7722337122613212119932404007801111~ NM1QC1DOESANDY***MISJD11112~ NM1821BANERIN***XX1811901945~ AMTAU132~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D02202514~ DTM47220190324~ CASCO4511~ AMTB614~ SVCAD>D02302210~ DTM47220190324~ CASCO4512~ AMTB610~ SVCAD>D02746034~ DTM47220190324~ CASCO4526~ AMTB634~ SVCAD>D11107349~ DTM47220190324~ CASCO4524~ AMTB649~ CLP7722337111974*12119932404007801111~ NM1QC1DOESALLY***MISJD11111~ NM1IL1DOEJOHN***MISJD11111~ NM1821BANERIN***XX1811901945~ AMTAU74~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D11107349~ DTM47220190324~ CASCO4524~ AMTB649~ CLP772233712261082412119932404007801111~ NM1QC1SMITHSALLY**MISJD11113~ NM1821BANERIN***XX1811901945~ AMTAU132~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 113/125 AMTB625~ SVCAD>D0220250~ DTM47220190324~ CASPR314~ CASCO4511~ AMTB614~ SVCAD>D0230220~ DTM47220190324~ CASPR310~ CASCO4512~ AMTB610~ SVCAD>D02746034~ DTM47220190324~ CASCO4526~ AMTB634~ SVCAD>D11107349~ DTM47220190324~ CASCO4524~ AMTB649~ CLP7722337111451490212119932404007801111~ NM1QC1SMITHSAM**MISJD11116~ NM1821BANERIN***XX1811901945~ AMTAU14~ SVCAD>D02202514~ DTM47220190324~ CASCO4511~ AMTB614~ SVCAD>D27909400~ DTM47220190324~ CASPR3756~ CASCO45184~ SVCAD>D29501800~ DTM47220190324~ CASPR3146~ CASCO4534~ CLP7722337134816.844.212119932404007801111~ NM1QC1JONESSAM**MISJD11122~ NM1821BANERIN***XX1811901945~ AMTAU28~ SVCAD>D43421250~ DTM47220190313~ CASCO45125~ SVCAD>D4381430~ DTM47220190313~ CASPR333~ CASCO4510~ SVCAD>D295018016.8~ DTM47220190313~ CASPR311.2~ CASCO45152~ AMTB628~ CLP77223371226132*12119932404007801111~ NM1QC1JONESSALLY***MISJD11133~ NM1821BANERIN***XX1811901945~ AMTAU132~ SVCAD>D01204625~ DTM47220190321~ CASCO4521~ AMTB625~ SVCAD>D02202514~ 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 114/125 DTM47220190321~ CASCO4511~ AMTB614~ SVCAD>D02302210~ DTM47220190321~ CASCO4512~ AMTB610~ SVCAD>D02746034~ DTM47220190321~ CASCO4526~ AMTB634~ SVCAD>D11107349~ DTM47220190321~ CASCO4524~ AMTB649~ CLP77223371179108*12119932404007801111~ NM1QC1DOESAM***MISJD99999~ NM1821BANERIN***XX1811901945~ AMTAU108~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D02746034~ DTM47220190324~ CASCO4526~ AMTB634~ SVCAD>D11107349~ DTM47220190324~ CASCO4524~ AMTB649~ CLP7722337112982*12119932404007801111~ NM1QC1DOESUE***MISJD88888~ NM1821BANERIN***XX1811901945~ AMTAU82~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D11205437~ DTM47220190324~ CASCO4517~ AMTB637~ SVCAD>D12082920~ DTM47220190324~ CASCO459~ AMTB620~ CLP77223371221144*12119932404007801111~ NM1QC1DOEDONNA***MISJD77777~ NM1821BANERIN***XX1811901945~ AMTAU144~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D03309262~ DTM47220190324~ CASCO4530~ AMTB662~ SVCAD>D11205437~ 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 115/125 DTM47220190324~ CASCO4517~ AMTB637~ SVCAD>D12082920~ DTM47220190324~ CASCO459~ AMTB620~ SE18335681~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 116/125 Example 3: Claim Specific Negotiated Discount ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83535681~ BPRI132CCHK***********20190331~ TRN1123451512345678~ REFEVCLEARINGHOUSE~ N1PRDELTA DENTAL OF ABC~ N3225 MAIN STREET~ N4CENTERVILLEPA17111~ PERBLJANE DOETE9005555555~ N1PEBAN DDS LLCFI999994703~ LX1~ CLP7722337122613212119932404007801~ NM1QC1DOESALLY***MISJD11111~ NM1821BANERIN***XX1811901945~ AMTAU132~ SVCAD>D01204625~ DTM47220190324~ CASCO13121~ AMTB625~ SVCAD>D02202514~ DTM47220190324~ CASCO13111~ AMTB614~ SVCAD>D02302210~ DTM47220190324~ CASCO13112~ AMTB610~ SVCAD>D02746034~ DTM47220190324~ CASCO13126~ AMTB634~ SVCAD>D11107349~ DTM47220190324~ CASCO13124~ AMTB649~ SE3535681~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 117/125 Example 4: Claim Adjustment Reason Code 45 ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI80.00CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLPPATACCT140080MCCLAIMNUMBER111~ NM1QC1DOEJOHNN*MIABC123456789~ REF1L12345F~ DTM05020190209~ PERCXG CUSTOMER SERVICE DEPARTMENTTE8004074627~ AMTAU150~ SVCHC>99213150801~ DTM47220190101~ CASCO4570~ AMTB680~ SVCHC>8500310001~ DTM47220190101~ CASCO204100~ SVCHC>3641515001~ DTM47220190101~ CASCO97150~ SE3310060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 118/125 Example 5a: Line Service Tax impacting payment only ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI11.06CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLPPCN136.2011.0612CLAIMNUMB111~ NM1QC1LASTFIRSTJ*MI123456789~ NM1821*****XX1447481825~ MOA**N25~ REF1L102345~ REFEA065789~ DTM05020170113~ AMTAU36.20~ SVCHC>9921426.23.06~ DTM47220170109~ CASCO4523.2137-.06~ REF6RB1~ AMTB63~ SVCHC>36415108~ DTM47220170109~ CASCO452~ REF6RB2~ AMTB68~ SE3510060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 119/125 Example 5b: Line Service Bonuses impacting payment only ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI12.00CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLPPCN125121012CLAIMNUMB111~ NM1QC1LASTFIRSTJ*MI123456789~ NM1821*****XX1447481825~ MOA**N25~ REF1L102345~ REFEA065789~ DTM05020170113~ AMTAU25~ SVCHC>992142512~ DTM47220170109~ CASCO455161-2~ CASPR310~ REF6R123~ AMTB620~ SE3110060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 120/125 Example 5c: Line Service Penalty impacting payment only ISA00* 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI8.00CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLPPCN12581012CLAIMNUMB111~ NM1QC1LASTFIRSTJ*MI123456789~ NM1821*****XX1447481825~ MOA**N25~ REF1L102345~ REFEA065789~ DTM05020170113~ AMTAU25~ SVCHC>99214258~ DTM47220170109~ CASCO455B42~ CASPR310~ REF6R123~ AMTB620~ SE3110060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 121/125 Example 6: Not Covered/Not Authorized Inpatient Facility claim days ISA00* 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI8000.00CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLPPATACCT1400008000MCCLAIMNUMBER111~ CASCO197200014530000~ NM1QC1DOEJOHNN*MIABC123456789~ REF1L12345F~ DTM23220190101~ DTM23320190105~ DTM05020190209~ PERCXG CUSTOMER SERVICE DEPARTMENTTE8004001212~ AMTAU38000~ QTYCA4~ SE2710060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 122/125 Example 8a: Claim submitted with incorrect subscriber as patient and incorrect ID ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P\|~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI120.03CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLP04777796TLC7771221155120.03138838888212111~ NM1QC1MASTERSMARVINL*MI80444444403~ NM1IL1CABLEMABEL***MI80444444403~ NM1741MASTERSMARVIN***C80444444401~ NM1821SHELTON MDBLAKE***XX1666666666~ REF1L28~ REFCEHSOAP-LAOA~ REFTJ555555555~ DTM23220191114~ DTM23320181114~ DTM05020181119~ AMTAU155~ SVCHC\|99393155120.031~ DTM47220181114~ CASCO4534.97~ REFLU11~ REF6R22261822~ AMTB6120.03~ SE3510060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 123/125 Example 8b: Claim submitted with incorrect subscriber name and ID ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P\|~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI35.06CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLP02333TLC222222111535.0635138333333214111~ NM1QC1KEATONALEXP*MI80000006006~ NM1IL1THOMASJASON***MI80000006006~ NM1741JEROME*C80000006001~ NM1821BLOOD MDRED N***XX1888888886~ REF1L28~ REFCEOAPOS-LAOA~ DTM23220191113~ DTM23320191113~ DTM05020191119~ AMTAU115~ SVCHC\|9921311535.061~ DTM47220191113~ CASCO4544.94~ CASPR335~ REFLU11~ REF6R22261389~ AMTB670.06~ SE3510060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 124/125 Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation. Example 8c: Claim submitted with for subscriber missing the Middle initial ISA00* 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI2415.25CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLP05444444TLC999999139032415.25138777777782211~ NM1QC1GONZALESSAMMY***MI80455555502~ NM1IL1LAPLANTEFERN***MI80455555502~ NM1741**R~ NM1821GOOD MDROBERT B**XX19999999987~ REF1L28~ REFCEOAPOS-LAOA~ DTM23220191101~ DTM23320191101~ DTM05020191114~ AMTAU3903~ AMTF5150~ SVCHC>5940039032415.251~ DTM47220191101~ CASCO451487.75~ REFLU21~ REF6R22215592~ AMTB62415.25~ SE3510060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 125/125	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
GAINWELL TECHNOLOGIES Louisiana Medicaid 837 Health Care Claim-Institutional Companion Guide Based on ASC X12N Version 005010X223A2 CORE v5010 Master Companion Guide Template Issued January 2018 Version 1.6 Revised 1/14/2025 837 Institutional Companion Guide i Revision History See Appendix C. Usage Information Documents published herein are furnished “As Is.” There are no expressed or implied warranties. The content of this document herein is subject to change without notice. 837 Institutional Companion Guide ii Preface This Companion Guide to the v5010 ASC X12N Implementation Guides and associated errata adopted under HIPAA clarifies and specifies the data content when exchanging electronically with Gainwell Medicaid Solutions. Transmissions based on this Companion Guide, used in tandem with the v5010 ASC X12N Implementation Guides, are compliant with both ASC X12 syntax and those guides. This Companion Guide is intended to convey information that is within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. The purpose of this guide is to clarify Louisiana Medicaid specific requirements and information needed for inclusion in the electronic 005010X223A2.claim transaction. The Companion Guide does not replace the published HIPAA Implementation TR3 Guide nor is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides. All Data must be formatted in upper case. This Guide is applicable to the following Louisiana Medicaid Claim types or File extensions. UB9 Inpatient and outpatient claims HOM Home Health claims XXA Medicare Advantage claims Providers/Submitters must be enrolled and registered in Louisiana Medicaid to submit electronic claims. Please review the 5010 EDI General Companion Guide: (https://www.lamedicaid.com/Provweb1/HIPAABilling/5010_EDI_General_Companion.pdf). Refer to Sections 2, 3 and 4 of this 837I guide for more detailed information. 837 Institutional Companion Guide iii TABLE OF CONTENTS PREFACE ...................................................................................................................................................... II 1. INTRODUCTION............................................................................................................................ 4 1.1 Scope .......................................................................................................................................... 4 1.2 Overview .................................................................................................................................... 5 1.3 References .................................................................................................................................. 5 1.4 Additional Information ............................................................................................................ 6 2. GETTING STARTED ............................................................................................................................. 6 2.1 Working with Louisiana Medicaid .......................................................................................... 6 2.2 Trading Partner Registration .................................................................................................. 6 2.3 Certification and Testing Overview ........................................................................................ 7 3. TESTING WITH THE PAYER .............................................................................................................. 7 4. CONNECTIVITY WITH THE PAYER /COMMUNICATIONS....................................................... 7 4.1 Process Flows ............................................................................................................................. 7 4.2 Transmission Administrative Procedures .............................................................................. 8 4.3 Re-Transmission Procedure ..................................................................................................... 8 4.4 Communication Protocol Specifications ................................................................................. 8 4.4.1 EDI Gateway – sFTP Process .................................................................................................. 8 4.4.2 File Naming Conventions – Production and Test File Names ............................................... 9 4.5 Passwords .................................................................................................................................. 9 5. CONTACT INFORMATION ................................................................................................................. 9 5.1 EDI Customer Service .............................................................................................................. 9 5.2 EDI Technical Assistance ......................................................................................................... 9 5.3 Provider Service & Provider Enrollment ............................................................................... 9 5.4 Applicable Websites/Email ...................................................................................................... 10 6. CONTROL SEGMENTS/ENVELOPES ............................................................................................... 10 6.1 ISA-IEA ...................................................................................................................................... 10 6.2 GS-GE ........................................................................................................................................ 11 6.3 ST-SE ......................................................................................................................................... 11 7. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS ......................................................... 11 8. ACKNOWLEDGEMENTS AND/OR REPORTS ................................................................................ 13 8.1 Report Inventory ....................................................................................................................... 13 9. TRADING PARTNER AGREEMENTS ............................................................................................... 13 9.1 Trading Partners ....................................................................................................................... 14 10. TRANSACTION SPECIFIC INFORMATION .................................................................................. 14 APPENDICES ............................................................................................................................................... 40 Appendix A – Implementation Checklist ....................................................................................... 40 Appendix B – Business Scenarios and Claim/Encounter Example ............................................. 40 a. Scenario 1 - CLAIMs FOR DUAL MEDICAID/MEDICARE ELIGIBLE WHEN DENIED BY MEDICARE ................................................................................................................................. 42 b. Scenario 2 - CLAIMS FOR RECIPIENTS WITH MEDICARE ADVANTAGE COVERAGE 44 c. Scenario 3 – ENCOUNTERS FOR SUBROGATION ................................................................. 48 Appendix C - Change Summary ..................................................................................................... 49 Appendix D - Trading Partner Agreements (TPA) ...................................................................... 50 837 Institutional Companion Guide 4 1. Introduction This section describes how Louisiana Medicaid specific Health Care Claim (837I) transaction set information will be detailed with the use of a table. The tables contain a row for each segment that Louisiana Medicaid has something additional, over and above, the information in the Technical Report Type 3 (TR3). That information can: • Limit the repeat of loops, or segments. • Limit the length of a simple data element. • Specify a sub-set of the Implementation Guides internal code listings. • Clarify the use of loops, segments, composite and simple data elements. • Any other information tied directly to a loop, segment, composite or simple data element pertinent to trading electronically with Louisiana Medicaid. In addition to the row for a specific segment, one or more additional rows are used to describe Louisiana Medicaid’s usage for composite and simple data elements and for any other information. Table 1: 837I Transaction Set Descriptions specifies the columns and suggested use of the rows for the detailed description of the transaction set Companion Guides. Table 1: 837I Transaction Set Descriptions Page # Loop ID Reference Name Codes Length Notes/Comments 2010B A NM1 Subscriber Name This type of row always exists to indicate that a new segment has begun. It is always shaded and notes or comments about the segment itself go in this cell. 2010B A NM109 Identification Code 2/80 This type of row exists to limit the length of the specified data element. 2430 SVD01 Identification Code <Third Party Carrier Code> Enter the Louisiana Medicaid issued Third Party Carrier Code. 1.1 Scope The purpose of the Louisiana Medicaid 837I Health Care Claim Companion Guide is to provide Trading Partners with a guide to the Louisiana Medicaid specific requirements for the 837 Institutional claim transactions. This Companion Guide document should be used in conjunction with the Technical Report Type 3 (TR3) and the national standard code sets referenced in that Guide. 837 Institutional Companion Guide 5 The 837I claims transaction is used for submittal of the following Louisiana Medicaid claim types, each with a unique file extension as part of the naming convention for the submitted file: UB9 – Inpatient and Outpatient claims. HOM – Home Health claims. Additional information about naming convention and file extensions can be found in the HIPAA 5010A EDI General Companion Guide (https://www.lamedicaid.com/Provweb1/HIPAABilling/5010_EDI_General_Companion.pdf). 1.2 Overview This companion guide is to assist trading partners test and set up electronic claim transactions to meet Louisiana Medicaid processing standards. It documents and clarifies which data elements and segments must be used and when specific code sets or codes are to be used with Louisiana Medicaid billings. The information in this guide must be used in conjunction with the TR3 Implementation Guide instructions. This section describes how the table, for the Louisiana Medicaid specific 837I transaction, is organized by columns and their descriptions. Section 10, Table 2 837I Health Care Claim, should be used as a reference for 837I transactions submitted to Louisiana Medicaid. Table 2 contains the specific data values and descriptions used in processing the transaction. Refer to Section 10, Transaction Set Information, for more details. Column Descriptions: • Page Number – Corresponding page number in TR3 Implementation Guide • Loop ID – TR3 Implementation Guide Loop • Reference – TR3 Implementation Guide Segment • Name – TR3 Implementation Guide segment/element name • Codes - Data values to be sent for Louisiana Medicaid transactions. Information contained within “< >” is the description or format of the data that should be entered in the field. • Length – A single number denotes fixed length. Two numbers separated by a slash denotes min/max length. • Notes/Comments – Additional information specific to Louisiana Medicaid transactions. 1.3 References This section describes the additional reference material Trading Partners must use for the specific transaction specifications for the 837I Health Care Claim. Refer to the following HIPAA version 5010A2 Technical Report Type 3 for additional information not supplied in this document, such as transaction usage, examples, code lists, definitions, and edits. • 837 Health Claim-Institutional • 005010X223A2 Copies of the ANSI X12 Technical Report Type 3s are available for purchase from the Washington Publishing Company at the following URL: http://www.wpc-edi.com. 837 Institutional Companion Guide 6 All required information for populating the X12 EDI transactions can be found by referencing this Louisiana Medicaid 837I Companion Guide and the HIPAA Technical Report Type 3s. 1.4 Additional Information Refer to the 5010A1 Technical Report Type 3 for information not supplied in this document, such as code sources, definitions, and edits. Louisiana Medicaid policies and requirements are documented in the claim type specific provider billing manuals and training packets and provider notices found on www.lamedicaid.com. 2. Getting Started This section describes how to interact with Louisiana Medicaid regarding 837I transactions. 2.1 Working with Louisiana Medicaid The EDI Help Desk is available to assist providers with their electronic transactions from, Monday through Friday, during the hours of 8:00 am – 5:00 pm Central, by calling 225-216-6303 or via email at [email protected]. Louisiana Medicaid’s MMIS system supports the following categories of Trading Partner: • Provider • Billing Agency • Clearinghouse • Health Plan NOTE: Providers must be enrolled and approved before registering as a Trading Partner. Billing Agencies/Clearinghouse must be associated with an approved Billing Provider in order to register as a Trading Partner. 2.2 Trading Partner Registration To obtain a Submitter ID visit the website: lamedicaid.com and follow the steps provided in the link titled Provider Enrollment. Providers may have up to three billing agencies/clearinghouse submit claims on their behalf but can select only one submitter to receive the 835 transaction. This selection is made when completing the ERA enrollment forms. All claims processed for a provider in a check write cycle will be included in the 835, regardless of method of submission (i.e. hardcopy or electronic). 837 Institutional Companion Guide 7 2.3 Certification and Testing Overview All Trading Partners are required to submit test EDI transactions before being authorized to submit production EDI transactions. The Usage Indicator, element 15 of the Interchange Control Header (ISA) of any X12 file, indicates if a file is test or production. Authorization is granted on a per transaction basis. For example, a trading partner may be certified to submit 837P professional claims, but not certified to submit 837I institutional claim files 3. Testing with the Payer Trading Partners will submit two test files of a particular transaction type, with no set minimum of transactions within each file, and have no failures or rejections to become certified for production. Users will be notified (E-mail) of the Trading Partner Status when testing for a particular transaction has been completed. To test an EDI transaction type, follow the steps outlined in Section 3 in the HIPAA 5010A EDI General Companion Guide (https://www.lamedicaid.com/Provweb1/HIPAABilling/5010_EDI_General_Companion.pdf). This guide provides additional information such as specific steps to follow for submitting test files, the test result reports and how to read them, file rejection reasons, etc. 4. Connectivity with the Payer /Communications This section contains information relating to the exchange methods with Louisiana Medicaid for submittal of the 837I transaction. 4.1 Process Flows Submitters will use the Louisiana Medicaid EDI Gateway to submit and retrieve files electronically. Each submitter receives a “mailbox” where their files are stored and maintained. This mailbox is accessed to send files via the “To_Molina” folder and retrieve files via the “From_Molina” folder. 837I files are sent to the submitter’s “To_Molina” folder and associated processing reports must be retrieved from the “From_Molina” folder location. Louisiana Medicaid has established the following for the EDI Gateway: • Internet sFTP Connection Services: Secure File Transfer Protocol to provide an end-to-end secure tunnel with Public/Private Key pair data encryption. Only Trading Partners who are approved to utilize this type of connection service may do so to submit 837I claim transactions to their secure FTP location. During the testing process with EDI Department, submitters will finalize the communication methodology to be used for file submissions and file retrievals. 837 Institutional Companion Guide 8 4.2 Transmission Administrative Procedures The TA1 and 999 transaction reports are posted to sFTP indicating whether a file has passed editing and been accepted for processing. These reports can be obtained from sFTP in the “From_Molina” folder for those submitters approved for that option. The deadline for claim file submission is noon on Monday through Thursday for processing in the weekend adjudication cycle. Claim files received Friday thru Sunday will be entered into the processing Daily cycle on Mondays. The Louisiana Medicaid calendar year check write schedule is posted to www.lamedicaid.com. Any variances in the check write schedule will be posted in provider notice section of www.lamedicaid.com. 4.3 Re-Transmission Procedure Providers/submitters should contact the Gainwell EDI Department via email at [email protected] if an 837I claim file is processed late or missing. If a file is rejected, the errors must be corrected and then the file can be resubmitted but MUST have a different ISA number. An ISA number can	837_Institutional_Companion_Guide.pdf
All Trading Partners are required to submit test EDI transactions before being authorized to submit production EDI transactions. The Usage Indicator, element 15 of the Interchange Control Header (ISA) of any X12 file, indicates if a file is test or production. Authorization is granted on a per transaction basis. For example, a trading partner may be certified to submit 837P professional claims, but not certified to submit 837I institutional claim files 3. Testing with the Payer Trading Partners will submit two test files of a particular transaction type, with no set minimum of transactions within each file, and have no failures or rejections to become certified for production. Users will be notified (E-mail) of the Trading Partner Status when testing for a particular transaction has been completed. To test an EDI transaction type, follow the steps outlined in Section 3 in the HIPAA 5010A EDI General Companion Guide (https://www.lamedicaid.com/Provweb1/HIPAABilling/5010_EDI_General_Companion.pdf). This guide provides additional information such as specific steps to follow for submitting test files, the test result reports and how to read them, file rejection reasons, etc. 4. Connectivity with the Payer /Communications This section contains information relating to the exchange methods with Louisiana Medicaid for submittal of the 837I transaction. 4.1 Process Flows Submitters will use the Louisiana Medicaid EDI Gateway to submit and retrieve files electronically. Each submitter receives a “mailbox” where their files are stored and maintained. This mailbox is accessed to send files via the “To_Molina” folder and retrieve files via the “From_Molina” folder. 837I files are sent to the submitter’s “To_Molina” folder and associated processing reports must be retrieved from the “From_Molina” folder location. Louisiana Medicaid has established the following for the EDI Gateway: • Internet sFTP Connection Services: Secure File Transfer Protocol to provide an end-to-end secure tunnel with Public/Private Key pair data encryption. Only Trading Partners who are approved to utilize this type of connection service may do so to submit 837I claim transactions to their secure FTP location. During the testing process with EDI Department, submitters will finalize the communication methodology to be used for file submissions and file retrievals. 837 Institutional Companion Guide 8 4.2 Transmission Administrative Procedures The TA1 and 999 transaction reports are posted to sFTP indicating whether a file has passed editing and been accepted for processing. These reports can be obtained from sFTP in the “From_Molina” folder for those submitters approved for that option. The deadline for claim file submission is noon on Monday through Thursday for processing in the weekend adjudication cycle. Claim files received Friday thru Sunday will be entered into the processing Daily cycle on Mondays. The Louisiana Medicaid calendar year check write schedule is posted to www.lamedicaid.com. Any variances in the check write schedule will be posted in provider notice section of www.lamedicaid.com. 4.3 Re-Transmission Procedure Providers/submitters should contact the Gainwell EDI Department via email at [email protected] if an 837I claim file is processed late or missing. If a file is rejected, the errors must be corrected and then the file can be resubmitted but MUST have a different ISA number. An ISA number can never be reused. 4.4 Communication Protocol Specifications This section describes Louisiana Medicaid’s communication protocol. The information exchanged between devices, through a network or other media, is governed by rules and conventions that can be set out in a technical specification called communication protocol standards. The nature of the communication, the actual data exchanged and any state-dependent behaviors, is defined by its specification. 4.4.1 EDI Gateway – sFTP Process Louisiana Medicaid offers a secure FTP system that has been developed to allow for more reliable and expedited electronic file exchanges for trading partners. The site is located at ftp.lamedicaid.com. To facilitate increased security requirements, all files sent to and received from the Gainwell sFTP site must be encrypted using Public/Private key pair encryption technology. Gainwell assumes any trading partner requesting access to the system will be familiar with how this technology is used. Gnu Privacy Guard, a free open source client, is available at http://www.gnupg.org . Symantec’s PGP client is another client although it is not free. 837 Institutional Companion Guide 9 4.4.2 File Naming Conventions – Production and Test File Names All electronic files sent to Gainwell must have file names in accordance with the structure below. Replace the sample submitter number of 4599999 with your assigned Louisiana Medicaid submitter number. The correct file extension is crucial to having your claims edited for the correct claim type. Transaction Claim Type Name File Extension Sample file name 837I 01,03 Institutional .UB9 H4599999.UB9 837I 06 Home Health .HOM H4599999.HOM 837I 14 Medicare Advantage .XXA H4599999.XXA 4.5 Passwords Trading Partners will be assigned a username and password during the Trading Partner Account registration process. Information for setting up the username and password is provided in Section 4.2 of the HIPAA 5010A EDI General Companion Guide located at lamedicaid.com under the HIPAA Information link. 5. Contact Information This section contains the contact information, including email addresses, for EDI Customer Service and Technical Assistance, Provider Services, and Provider Enrollment. All times are Central Time Zone. 5.1 EDI Customer Service The EDI Help Desk is available to assist providers with their electronic transactions from Monday through Friday, during the hours of 8:00 am – 5:00 pm, by calling 1-225-216-6303. Or via email at [email protected] 5.2 EDI Technical Assistance The EDI Help Desk is available to assist providers with their electronic transactions from Monday through Friday, during the hours of 8:00 am – 5:00 pm, by calling 1-225-216-6303. 5.3 Provider Service & Provider Enrollment The Provider Services Call Center is available to assist providers concerning the payment of claims from Monday through Friday, during the hours of 8:00 am – 5:00 pm, by calling 1-225-924-5040 or 1-800- 473-2783. The Provider Enrollment Department is available to assist provider with enrollment, changes to submitters, etc., Monday through Friday, during the hours of 8:00 am – 5:00 pm by calling 1-225-216- 6370. 837 Institutional Companion Guide 10 5.4 Applicable Websites/Email For questions related to electronic Data interchange and EDI issues, the EDI Department can be contacted at: [email protected]. 6. Control Segments/Envelopes This section describes Louisiana Medicaid’s use of the interchange, functional group control segments and the transaction set control numbers. 6.1 ISA-IEA This section describes Louisiana Medicaid’s use of the interchange control segments. Interchange Control Header • ISA01, Authorization Information Qualifier, Value will be 00. • ISA02, Authorization Information, Value will be spaces. • ISA03, Security Information Qualifier, Value will be 00. • ISA04, Security Information, Value will be spaces. • ISA05, Interchange ID Qualifier, Value will be ZZ. • ISA06, Interchange Sender ID: Value will be the 7 digit Gainwell assigned Submitter ID (i.e. 450XXXX) followed by spaces. • ISA07, Interchange ID Qualifier: Value will be ZZ. • ISA08, Interchange Receiver ID: Value will be LA-DHH-MEDICAID. • ISA09, Interchange Date: The date format is YYMMDD. • ISA10, Interchange Time: The time format is HHMM. • ISA 11, Repetition Separator: Value will be ^ ASCIIx5E. • ISA12, Interchange Control Version Number: Value will be 00501. • ISA13, Interchange Control Number, Value will be identical to the interchange trailer IEA02. Must be a positive unsigned number and must be unique for every transmission submitted. • ISA14, Acknowledgment Requested, Value will be 0 or 1. • ISA15, Usage Indicator, T = Test Data and P=Production Data. • ISA16, Component Element Separator: Must be a colon: ASCIIx3A. 837 Institutional Companion Guide 11 • Interchange Control Trailer • IEA01, Number of included Functional Groups. • IEA02, Interchange Control Number, Value must be identical to value in ISA13 6.2 GS-GE This section describes Louisiana Medicaid’s use of the functional group control segments. Functional Group Header • GS01, Functional Identifier Code: Value will be HC for this element. • GS02, Application Sender’s Code: Value must be identical to ISA06. • GS03, Application Receiver’s Code: Value will be LA-DHH-MEDICAID. • GS04, Date: The date format is CCYYMMDD. • GS05, Time: The time format is HHMM. • GS06, Group Control Number: Uniquely assigned and maintained by the sender. • GS07, Responsible Agency Code: Value will be X. • GS08, Version/Release/Industry Identifier Code: Value will be 005010X223A2. Functional Group Trailer • GE01, Number of Transaction Sets included. • GE02, Group Control Number; Value must be identical to value in GS06. 6.3 ST-SE This section describes Louisiana Medicaid’s use of the transaction set control numbers. • ST02, Transaction Set Control Number: Must be identical to associated Transaction Set Control Number SE02. • ST03, Implementation Convention Reference: Value will be 005010X223A2. • SE02, Transaction Set Control Number: Must be identical to ST02. Only one ST-SE transaction loop is permitted per file. 7. Payer Specific Business Rules and Limitations This section describes Louisiana Medicaid’s business rules regarding 837I transactions. 837 Institutional Companion Guide 12 Service line data is required when reporting inpatient, outpatient and home health claims or when payment adjustments (reduction to billed charges or denial) are related to specific claim lines. Since Louisiana Medicaid is a claim line processor, all adjustments are line specific, except for inpatient institutional claims when the per-diem is the only service line adjustment. Each claim line (other than inpatient) will be reported in the 835 as a claim. Data not supplied at the claim level must be supplied at the line level (SVC – Service Payment Information). There is a limit of 20,000 CLM segments in a claims file. NOTE: National Provider Identification Numbers are to be submitted in all 837I transactions. Atypical providers who have not registered an NPI with Louisiana Medicaid may continue to submit their legacy Medicaid Provider ID in the 837I as the provider identifier. All successful 837I transactions received prior to cutoff on Thursdays will be processed in a Weekly Adjudication cycle with payment by check or EFT scheduled for the following Tuesday. Exceptions to this schedule will be posted on lamedicaid.com. For Louisiana Medicaid claims, the Patient and the Subscriber are always the same, therefore Patient level data should not be sent. For Louisiana Medicaid’s specific business rules and limitations, refer to Section 10 Transaction Set Information, Table 2: 837I Health Claim. Coordination of Benefits (COB)--For the purposes of COB, there are two types of payers in the 837; (1) the destination payer defined in the 2010BB loop, and (2) any ’other’ payers defined in the 2330B loop(s). All of the information contained in the 2300 and 2310 loops is specific to the destination payer described in the 2010BB loop. Information specific to other payers is contained in the 2320, 2330, and 2430 loops. Description 837 Loop Segment Data Source Claim Adjustment Group Code Loop 2320 CAS Segment(s) Other Third Party 835 or EOB Payer Paid Amount Loop 2320 AMTD Segment (Qualifier D) Other Third Party 835 or EOB Remaining Patient Liability Loop 2320 AMTEAF Segment (use here when only claim level COB info provided) Calculated by Provider Claim Adjudication Date Loop 2330B DTP Segment Other Third Party 835 or EOB Service Line Paid Amount Loop 2430 SVD Segment Other Third Party 835 or EOB Claim Adjustment Group Code Loop 2430 CAS Segment(s) Other Third Party 835 or EOB Line Adjudication Date Loop 2430 DTP Segment Other Third Party 835 or EOB 837 Institutional Companion Guide 13 Remaining Patient Liability Loop 2430 AMT*EAF Segment (Use here when line level COB info provided) Calculated by Provider There may be other payers involved with a claim; therefore, there could be more than 1 set of COB data. If that is the situation, the other Third Party’s Louisiana Carrier Code, Paid Amount, Paid Date and CAS Segments would also be reported. Other payers must be identified in the 837 Transaction in Loop 2330B; Segment NM109 with the six- digit Louisiana Medicaid assigned Carrier Code. The Carrier codes may be found on www.lamedicaid.com under the Forms/Files/Surveys/User Manuals link. You may either enter the name of an insurer or download the complete Louisiana Carrier Code listing. 8. Acknowledgements and/or Reports HIPAA responses and acknowledgements are available for download via sFTP for a period of 14 days from the original creation date. 8.1 Report Inventory The TA1 notifies the sender that a valid envelope was received or that problems were encountered with the interchange control structure. The TA1 verifies the envelopes only. TA104, Interchange Acknowledgment Code, indicates the status of the interchange control structure. This data element stipulates whether the transmitted	837_Institutional_Companion_Guide.pdf
the line level (SVC – Service Payment Information). There is a limit of 20,000 CLM segments in a claims file. NOTE: National Provider Identification Numbers are to be submitted in all 837I transactions. Atypical providers who have not registered an NPI with Louisiana Medicaid may continue to submit their legacy Medicaid Provider ID in the 837I as the provider identifier. All successful 837I transactions received prior to cutoff on Thursdays will be processed in a Weekly Adjudication cycle with payment by check or EFT scheduled for the following Tuesday. Exceptions to this schedule will be posted on lamedicaid.com. For Louisiana Medicaid claims, the Patient and the Subscriber are always the same, therefore Patient level data should not be sent. For Louisiana Medicaid’s specific business rules and limitations, refer to Section 10 Transaction Set Information, Table 2: 837I Health Claim. Coordination of Benefits (COB)--For the purposes of COB, there are two types of payers in the 837; (1) the destination payer defined in the 2010BB loop, and (2) any ’other’ payers defined in the 2330B loop(s). All of the information contained in the 2300 and 2310 loops is specific to the destination payer described in the 2010BB loop. Information specific to other payers is contained in the 2320, 2330, and 2430 loops. Description 837 Loop Segment Data Source Claim Adjustment Group Code Loop 2320 CAS Segment(s) Other Third Party 835 or EOB Payer Paid Amount Loop 2320 AMTD Segment (Qualifier D) Other Third Party 835 or EOB Remaining Patient Liability Loop 2320 AMTEAF Segment (use here when only claim level COB info provided) Calculated by Provider Claim Adjudication Date Loop 2330B DTP Segment Other Third Party 835 or EOB Service Line Paid Amount Loop 2430 SVD Segment Other Third Party 835 or EOB Claim Adjustment Group Code Loop 2430 CAS Segment(s) Other Third Party 835 or EOB Line Adjudication Date Loop 2430 DTP Segment Other Third Party 835 or EOB 837 Institutional Companion Guide 13 Remaining Patient Liability Loop 2430 AMTEAF Segment (Use here when line level COB info provided) Calculated by Provider There may be other payers involved with a claim; therefore, there could be more than 1 set of COB data. If that is the situation, the other Third Party’s Louisiana Carrier Code, Paid Amount, Paid Date and CAS Segments would also be reported. Other payers must be identified in the 837 Transaction in Loop 2330B; Segment NM109 with the six- digit Louisiana Medicaid assigned Carrier Code. The Carrier codes may be found on www.lamedicaid.com under the Forms/Files/Surveys/User Manuals link. You may either enter the name of an insurer or download the complete Louisiana Carrier Code listing. 8. Acknowledgements and/or Reports HIPAA responses and acknowledgements are available for download via sFTP for a period of 14 days from the original creation date. 8.1 Report Inventory The TA1 notifies the sender that a valid envelope was received or that problems were encountered with the interchange control structure. The TA1 verifies the envelopes only. TA104, Interchange Acknowledgment Code, indicates the status of the interchange control structure. This data element stipulates whether the transmitted interchange was accepted with no errors, accepted with errors, or rejected because of errors. TA105, Interchange Note Code, is a numerical code that indicates the error found while processing the interchange control structure. For a listing and description of TA1 errors, refer to Section 4.6.4 in the HIPAA 5010A EDI General Companion Guide found on lamedicaid.com The 999 informs the submitter that the functional group arrived at the destination. It may include information about the syntactical quality of the functional group and the implementation guide compliance. Reason(s) for failure of claims files will be posted in the 999 which can be retrieved from sFTP. 9. Trading Partner Agreements A Trading Partner Agreement (TPA) is a legal contract between Gainwell, acting on behalf of the State of Louisiana, Department of Health and Hospitals and a provider/billing agent/clearinghouse/health plan, to exchange electronic information. The desire to exchange by and through electronic communications, certain claims and billing information that may contain identifiable financial and/or protected health information (PHI) as defined under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 Code of Federal Regulations Parts 160-164, and applicable regulations that implement Title V of the Gramm-Leach-Bliley Act, 15 U.S.C. § 6801, et seq. The parties agree to safeguard any and all PHI or other data received, transmitted or accessed electronically to or from each other in accordance with HIPAA. This agreement is within the TPA. 837 Institutional Companion Guide 14 Refer to the Provider Enrollment link on www.lamedicaid.com to obtain information about the TPA forms that are required for enrollment as an electronic claims submitter. 9.1 Trading Partners A Trading Partner is defined as any entity with which Gainwell exchanges electronic data. The term electronic data is not limited to HIPAA X12 transactions. Louisiana Medicaid’s Medicaid Management System supports the following categories of Trading Partner: • Provider • Billing Agency • Clearinghouse • Health Plan Gainwell will assign Trading Partner IDs (Submitter ID) to support the exchange of X12 EDI transactions for providers, billing agencies and clearinghouses, and other health plans. 10. Transaction Specific Information This section describes the Louisiana Medicaid specific 837 transaction set information requirements, which are outlined in Table 2: 837I Health Claim. The table contains a row for each segment that Louisiana Medicaid has something additional, over and above, the information in the Technical Report Type 3 (TR3). That information can: • Limit the repeat of loops, or segments. • Limit the length of a simple data element. • Specify a sub-set of the Implementation Guides internal code listings. • Clarify the use of loops, segments, composite and simple data elements. • Any other information tied directly to a loop, segment, composite and/or simple data element pertinent to trading electronically with Louisiana Medicaid. 837 Institutional Companion Guide 15 Table 2: 837I Health Claim TR3 Page # Loop ID Reference Name Codes Length Notes/Comments C.3 HEADER ISA Interchange Control Header ISA Element Separator 1 C.4 ISA06 Interchange Sender ID <7 digit Gainwell assigned Submitter number i.e.450XXXX> 15 Enter the Unique Submitter number issued by Gainwell to authorized EDI Submitters followed by spaces Element Separator * 1 C.5 ISA08 Interchange Receiver ID LA-DHH- MEDICAID 15 Element Separator * 1 C.6 ISA08 Interchange Receiver ID 0 or 1 1 0 = No Interchange Acknowledgement Requested 1 = Acknowledgement Requested ISA15 Interchange Usage Indicator P or T 1 P = Production Data T = Test Data Element Separator * 1 ISA16 Component Separator : 1 Must be a colon Segment End ~ 1 C.7 HEADER GS Functional Group Header GS Element Separator * 1 GS01 Functional Identifier Code HC 2 HC = Health Care Claim (837) Element Separator * 1 GS02 Application Sender's Code <Gainwell assigned Submitter ID> 2/15 Value will be identical to value in ISA06 Element Separator * 1 GS01 Functional Identifier Code HC 2 HC = Health Care Claim (837) 837 Institutional Companion Guide 16 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments Element Separator * 1 GS02 Application Sender's Code <Gainwell assigned Submitter ID> 2/15 Value will be identical to value in ISA06 Element Separator * 1 GS03 Application Receiver's Code LA-DHH- MEDICAID 2/15 Element Separator * 1 GS04 Date <CCYYMMDD> 8/8 NOTE: Use this date for the functional group creation date. Element Separator * 1 C.8 GS05 Time <HHMM> 4/8 NOTE: Use this time for the creation time. Element Separator * 1 GS06 Group Control Number <Assigned by Sender> 1/9 Uniquely assigned and maintained by the sender Element Separator * 1 GS07 Responsible Agency Code X 1/2 X = Accredited Standards Committee X12 GS08 Version / Release / Industry Identifier Code 005010X223A2 1/12 005010X223A2 = Standards Approved for Publication by ASC X12 Procedures Review Board 67 HEADER ST Transaction Set Header ST Element Separator * 1 ST02 Transaction Set Control Number <Assigned by Sender> 4/9 NOTE: Must be identical to associated Transaction Set Control Number SE02. Element Separator * 1 ST03 Implementation Convention Reference 005010X223A2 1/35 Contains the same value as in GS08. Segment End ~ 1 71 1000A NM1 Submitter Name N1 837 Institutional Companion Guide 17 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments Element Separator * 1 72 NM109 Identification Code <7 digit Louisiana Medicaid assigned Submitter Number> 2/80 Use the 7 digit Louisiana Medicaid Submitter ID assigned by Gainwell (i.e. 450XXXX). Segment End ~ 1 76 1000B NM1 Receiver Name Element Separator * 1 NM103 Name Last or Organization Name <Receiver Name> 1/60 Value is LOUISIANA MEDICAID Element Separator * 1 NM109 Identification Code <Receiver Code> 2/80 Value is LA-DHH- MEDICAID Segment End ~ 1 80 2000A PRV Billing Provider Specialty Information Element Separator * 1 PRV01 Provider Code <Provider Type Identifier Code> 1/3 Value is BI=Billing Provider Element Separator * 1 PRV02 Reference Identification Qualifier <Taxonomy Qualifier Code> 2/3 Value is PXC=Provider Taxonomy Code Element Separator * 1 837 Institutional Companion Guide 18 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments PRV03 Reference Identification <Provider Taxonomy Code> 1/50 Value is the taxonomy Codes associated with the NPI of the Billing Provider and registered with Louisiana Medicaid. In situations where a provider may have a single NPI associated with multiple LA Medicaid provider numbers, a tie-breaker such as taxonomy may be required for unique identification of the Medicaid provider ID. Use the same Taxonomy code that was registered with Louisiana Medicaid for the Billing Provider. 84 2010AA NM1 Billing Provider Name If the Billing provider is an atypical provider who has not been issued or registered an NPI with LA Medicaid, DO NOT USE this Loop. Use Loop 2010BB and report legacy Medicaid Provider ID in REF02 with Qualifier G2. Element Separator * 1 86 NM108 Identification Code Qualifier <Provider Identifier Qualifier Code> 1/2 Value is XX = NPI (National Provider Identifier) Element Separator * 1 NM109 Identification Code <Billing Provider NPI Identifier> 2/80 Value is the provider NPI registered with Louisiana Medicaid that corresponds to the LA Medicaid provider being reported in this Loop. . If an atypical provider who has registered an NPI with LA Medicaid, report the NPI in this Loop. Segment End ~ 1 837 Institutional Companion Guide 19 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 88 2010AA N4 Billing Provider City, State, Zip Code Element Separator * 1 89 N403 Postal Code <Postal Zip Code> 3/15 Value is the 9-digit Zip code. In situations where a provider may have a single NPI associated with multiple LA Medicaid provider numbers, a tiebreaker such as zip code may be required for unique identification of the Medicaid provider ID. Use the same zip code that was registered with Louisiana Medicaid for the Billing Provider. Segment End ~ 1 107 2000B HL Subscriber Hierarchical Level Element Separator * 1 108 HL04 Hierarchical Child Code 0 1/1 Value is 0 for this element. For LA Medicaid the subscriber will always equal the patient. Therefore, an additional subordinate HL is not required. Segment End ~ 1 109 2000B SBR Subscriber Information Element Separator * 1 110 SBR09 Claim Filling Indicator Code <Claim Filing Indicator Code> 1/2 Value is MC = Medicaid Segment End ~ 1 112 2010BA NM1 Subscriber Name Element Separator * 1 NM102 Entity Type Qualifier <Entity Type Qualifier> 1/1 Value is 1 837 Institutional Companion Guide 20 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments Element Separator * 1 NM108 Identification Code Qualifier <Member ID Qualifier> 1/2 Value is MI = Member Identification Element Separator * 1 NM109 Identification Code <13 digit Louisiana Medicaid Recipient ID Number> 2/80 Value is the thirteen digit Medicaid Recipient ID number Segment End ~ 1 122 2010BB NM1 Payer Name Element Separator * 1 124 NM108 Identification Code Qualifier <Code Qualifier> 1/2 Value is PI = Payer Identification Element Separator * 1 NM109 Identification Code LA-DHH- MEDICAID 2/80 Value is LA-DHH- MEDICAID Segment End ~ 1 129 2010BB REF Billing Provider Secondary Identification This Loop is used by atypical providers that DO NOT have an NPI registered with Louisiana Medicaid. If an atypical provider has an NPI, use Loop 2010AA NM109 REF segment and do not send this REF. Element Separator * 1 REF01 Reference Identification Qualifier <Reference Qualifier> 2/3 Value is G2 = Provider Commercial Number Element	837_Institutional_Companion_Guide.pdf
multiple LA Medicaid provider numbers, a tie-breaker such as taxonomy may be required for unique identification of the Medicaid provider ID. Use the same Taxonomy code that was registered with Louisiana Medicaid for the Billing Provider. 84 2010AA NM1 Billing Provider Name If the Billing provider is an atypical provider who has not been issued or registered an NPI with LA Medicaid, DO NOT USE this Loop. Use Loop 2010BB and report legacy Medicaid Provider ID in REF02 with Qualifier G2. Element Separator * 1 86 NM108 Identification Code Qualifier <Provider Identifier Qualifier Code> 1/2 Value is XX = NPI (National Provider Identifier) Element Separator * 1 NM109 Identification Code <Billing Provider NPI Identifier> 2/80 Value is the provider NPI registered with Louisiana Medicaid that corresponds to the LA Medicaid provider being reported in this Loop. . If an atypical provider who has registered an NPI with LA Medicaid, report the NPI in this Loop. Segment End ~ 1 837 Institutional Companion Guide 19 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 88 2010AA N4 Billing Provider City, State, Zip Code Element Separator * 1 89 N403 Postal Code <Postal Zip Code> 3/15 Value is the 9-digit Zip code. In situations where a provider may have a single NPI associated with multiple LA Medicaid provider numbers, a tiebreaker such as zip code may be required for unique identification of the Medicaid provider ID. Use the same zip code that was registered with Louisiana Medicaid for the Billing Provider. Segment End ~ 1 107 2000B HL Subscriber Hierarchical Level Element Separator * 1 108 HL04 Hierarchical Child Code 0 1/1 Value is 0 for this element. For LA Medicaid the subscriber will always equal the patient. Therefore, an additional subordinate HL is not required. Segment End ~ 1 109 2000B SBR Subscriber Information Element Separator * 1 110 SBR09 Claim Filling Indicator Code <Claim Filing Indicator Code> 1/2 Value is MC = Medicaid Segment End ~ 1 112 2010BA NM1 Subscriber Name Element Separator * 1 NM102 Entity Type Qualifier <Entity Type Qualifier> 1/1 Value is 1 837 Institutional Companion Guide 20 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments Element Separator * 1 NM108 Identification Code Qualifier <Member ID Qualifier> 1/2 Value is MI = Member Identification Element Separator * 1 NM109 Identification Code <13 digit Louisiana Medicaid Recipient ID Number> 2/80 Value is the thirteen digit Medicaid Recipient ID number Segment End ~ 1 122 2010BB NM1 Payer Name Element Separator * 1 124 NM108 Identification Code Qualifier <Code Qualifier> 1/2 Value is PI = Payer Identification Element Separator * 1 NM109 Identification Code LA-DHH- MEDICAID 2/80 Value is LA-DHH- MEDICAID Segment End ~ 1 129 2010BB REF Billing Provider Secondary Identification This Loop is used by atypical providers that DO NOT have an NPI registered with Louisiana Medicaid. If an atypical provider has an NPI, use Loop 2010AA NM109 REF segment and do not send this REF. Element Separator * 1 REF01 Reference Identification Qualifier <Reference Qualifier> 2/3 Value is G2 = Provider Commercial Number Element Separator * 1 130 REF02 Reference Identification <7-digit Louisiana Medicaid Provider ID> 1/50 Value is the 7 digit Louisiana Medicaid Provider Number Segment End ~ 1 143 2300 CLM Claim Information Element Separator * 1 837 Institutional Companion Guide 21 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 144 CLM01 Claim Submitter’s Identifier <Submitter’s Claim Identifier/Patient Account Number> 1/20 Enter a unique number up to 20 characters. Element Separator * 1 CLM02 Monetary Amount <Billed Charge Amount> 2/80 Enter the total charges for the billed services. This amount must be LESS than one million dollars. Element Separator * 1 145 CLM05 Health Care Service Location Information CLM05 information applies to all service lines unless over written at the line level. CLM05-1 Facility Code Value <First and second positions of the Uniform Bill Type Code > 1/2 The following bill type codes are the only ones acceptable for LA Medicaid Inpatient, Outpatient and HH claims plus Managed Care encounters. Use of any other bill type codes will result in claim file rejection. For file extension UB9 use 11,12,13,14,18,21,71,72,76, 81,82,83,85,86,89. For file extension HOM use 32. CLM05-2 Facility Type Code A 1/2 Value is A= Uniform Billing Claim Form Bill Type CLM05-3 Claim Frequency Type Code <Third position of the UB Bill Type Code> 1/1 Value 1 = Original claim Value 7 = Adjustment of a previous claim Value 8 = Void of a previous claim Element Separator * 1 153 2300 CL1 Institutional Claim Code Element Separator * 1 CL101 Admission Type Code <Code indicating admission priority> 1/1 Priority of Admission 837 Institutional Companion Guide 22 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments Element Separator * 1 CL102 Admission Source Code <Code indicating admission source> 1/1 Point of Origin for Admission Element Separator * 1 CL103 Patient Status Code <Code indicating patient status > 1/2 The patient status as of the statement through date Segment End ~ 1 2300 REF Service Authorization Exception Code Element Separator * 1 REF01 Reference Identification Qualifier <Reference Qualifier> 2/3 Value is 4N = Special Payment Reference Number Element Separator * 1 REF02 Reference Identification <Service Authorization Exception Code> 1/50 Value 1 = billing for services associated with low level complexity which corresponds to the level of care noted in the definition of Evaluation and Management CPT codes 99281 and 99282 Value 3 = billing for services associated with moderate to high level emergency physician care which corresponds to the level of care noted in the definition of Evaluation and Management CPT codes 99283, 99284 and 99285 Segment End ~ 1 2300 REF Prior Authorization Use this Segment if the extended Home Health or Hospice service was prior authorized by Louisiana Medicaid. Element Separator * 1 837 Institutional Companion Guide 23 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments REF01 Reference Identification Qualifier <Qualifier Code> 2/3 Value is G1 = La Medicaid Prior Authorization number Element Separator * 1 REF02 Reference Identification <Prior Authorization Number> 1/50 Value is the Gainwell assigned Prior Authorization Number for the service being billed. Segment End ~ 1 166 2300 REF Payer Claim Control Number Element Separator * 1 REF01 Reference Identification Qualifier <Qualifier Code> 2/3 Value is F8 = Original Reference Number Element Separator * 1 REF02 Reference Identification <Claim Internal Control Number> 1/50 Value is the Gainwell assigned 13-digit Internal claim number (ICN). Enter original ICN when billing for adjustment or void of claim. The ICN is required when CLM05-3 value is 7 or 8 Segment End ~ 1 2300 NTE Billing Note Element Separator * 1 NTE01 Note Reference Code <Qualifier Code> 3/3 Value is ADD when this segment sent Element Separator * 1 NTE02 Reference Identification <Note text> 1/80 LA Medicaid no longer requires the Mother’s Medicaid ID to be present on baby’s claim. Segment End ~ 1 184 2300 HI Principal Diagnosis . Element Separator * 1 837 Institutional Companion Guide 24 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments HI01-01 Code List Qualifier Code <Qualifier Code> 1/3 Value is ABK for service/discharge dates on or after 10/1/2015. Value is BK for service/discharge dates prior to 10/1/2015 Element Separator * 1 185 HI01-02 Principal Diagnosis Code < Diagnosis Code> 1/30 Value is the Principal Diagnosis code for the services being billed Element Separator * 1 HI01-09 Condition or Response Code <N,U,W or Y> 1/1 Use the appropriate Present on Admission indicator code as applied to the Principal Diagnosis Segment End ~ 1 187 2300 HI Admitting Diagnosis Element Separator * 1 188 HI01-01 Code List Qualifier Code <Qualifier Code > 1/3 Value is ABJ for admission date on or after 10/1/2015. Value is BJ for admission date prior to 10/1/2015 Element Separator * 1 HI01-02 Admitting Diagnosis Code <Diagnosis Code> 1/30 Value is the patient’s diagnosis upon admission to the facility Segment End ~ 1 2300 HI Other Diagnosis Information Enter additional HI Other Diagnosis Segments for conditions that coexist or develop during the patient’s treatment. You may enter up to 12 additional diagnosis codes. Element Separator * 1 HI01-01 Code List Qualifier Code < Qualifier Code> 1/3 Code BF = Use for service/discharge dates before 10/01/2015 Code ABF = Use for service/discharge dates on or after 10/01/2015 837 Institutional Companion Guide 25 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments Element Separator * 1 HI01-02 Industry Code < Diagnosis Code> 1/30 Value is ICD-9 codes for service/discharge dates before 10/01/2015; ICD-10 codes for service/discharge dates after 10/01/2015 Element Separator * 1 HI02-01 Code List Qualifier Code <Other Diagnosis Code Qualifier> 1/3 BF = Use for service/discharge dates before 10/01/2015 ABF = Use for service/discharge dates on or after 10/01/2015 Element Separator * 1 HI02-02 Industry Code <Other Diagnosis Code> 1/30 Value is ICD-9 codes for service/discharge dates before 10/01/2015; ICD-10 codes for service/discharge dates after 10/01/2015 Element Separator * 1 2300 HI Value Information Repeat Value Information segments as needed to report additional Value Codes Element Separator * 1 HI01-01 Code List Qualifier Code <Qualifier Code > 1/3 Value is BE Element Separator * 1 HI01-02 Value Code <Value Code> 2/3 Use code 80 for covered days Code 81 for non-cov days Code 82 for co-insur days Code 83 for Lifetime reserve days Element Separator * 1 837 Institutional Companion Guide 26 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments HI01-05 Value Code Amount <Quantity or Dollar Value> 1/8 Enter number or dollar value. Values greater than 999 are invalid for Value codes 80, 81, 82 or 83. If required to report Value code 61,enter the MSA or CBSA code (right justified) to the left of the decimal place; cannot exceed 000000.00 Element Separator * 1 2300 HI Condition Information Repeat Condition Information Segments as needed to report additional Condition Codes. Element Separator * 1 HI01-01 Code List Qualifier Code <Qualifier Code > 1/3 Value is BG Element Separator * 1 HI01-02 <Condition Code> 1/30 Value is A1 if the service has been rendered as a result of an EPSDT referral. Value is A4 if the service is related to family planning Element Separator * 1 319 2310A NM1 Attending Provider Name Effective July 1, 2015, the attending provider is required to be identified. The attending provider in this Loop applies to the entire claim unless overridden at the line level by the presence of Loop 2420C. Attending provider information is required when institutional claims contain any services other than non- scheduled transportation claims. Element Separator * 1 837 Institutional Companion Guide 27 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments NM101 Entity Identifier Code <Entity Code> 2/3 Value is 71 Element Separator * 1 321 NM108 Identification Qualifier Code <XX> 1/2 Value is XX = National Provider Identifier Element Separator * 1 NM109 Identification Code <NPI of Attending Provider> 2/80 Value is the NPI of the attending provider that is registered with the Louisiana Medicaid Program Segment End ~ 1 322 2310A PRV Attending Provider Specialty Information Element Separator * 1 PRV01 Provider Code < Provider Type Identifier Code> 1/3 Value is AT=Attending Provider Element Separator * 1 PRV02 Reference Identification Qualifier <Taxonomy Code Qualifier> 2/3 Value is PXC=Provider Taxonomy Code Element Separator * 1 PRV03 Reference Identification <Provider Taxonomy Code> 1/50 Value is the taxonomy Code associated with the NPI of the Attending Provider and registered with Louisiana Medicaid. In situations where a provider may have a single NPI associated with multiple LA Medicaid provider numbers, a tie- breaker such as taxonomy may be required for unique identification of the Medicaid provider ID. Use the same Taxonomy code that was registered with Louisiana Medicaid for the Attending Provider. 837 Institutional Companion Guide 28 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments Segment End ~ 1 324 2310A REF Attending Provider Secondary Identification Element Separator * 1 REF01 Reference Identification Qualifier G2 2/3 Value is G2 = Provider Louisiana Medicaid Number Element Separator * 1 REF02 Reference Identification <7-digit Louisiana Medicaid Provider ID> 1/50 Value is the 7-digit Medicaid provider number of an atypical provider who has not registered an NPI with Louisiana Medicaid. Otherwise, do not use this Loop. Segment End ~ 1 349 2310F Referring Provider Name If present, the Referring	837_Institutional_Companion_Guide.pdf
81 for non-cov days Code 82 for co-insur days Code 83 for Lifetime reserve days Element Separator * 1 837 Institutional Companion Guide 26 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments HI01-05 Value Code Amount <Quantity or Dollar Value> 1/8 Enter number or dollar value. Values greater than 999 are invalid for Value codes 80, 81, 82 or 83. If required to report Value code 61,enter the MSA or CBSA code (right justified) to the left of the decimal place; cannot exceed 000000.00 Element Separator * 1 2300 HI Condition Information Repeat Condition Information Segments as needed to report additional Condition Codes. Element Separator * 1 HI01-01 Code List Qualifier Code <Qualifier Code > 1/3 Value is BG Element Separator * 1 HI01-02 <Condition Code> 1/30 Value is A1 if the service has been rendered as a result of an EPSDT referral. Value is A4 if the service is related to family planning Element Separator * 1 319 2310A NM1 Attending Provider Name Effective July 1, 2015, the attending provider is required to be identified. The attending provider in this Loop applies to the entire claim unless overridden at the line level by the presence of Loop 2420C. Attending provider information is required when institutional claims contain any services other than non- scheduled transportation claims. Element Separator * 1 837 Institutional Companion Guide 27 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments NM101 Entity Identifier Code <Entity Code> 2/3 Value is 71 Element Separator * 1 321 NM108 Identification Qualifier Code <XX> 1/2 Value is XX = National Provider Identifier Element Separator * 1 NM109 Identification Code <NPI of Attending Provider> 2/80 Value is the NPI of the attending provider that is registered with the Louisiana Medicaid Program Segment End ~ 1 322 2310A PRV Attending Provider Specialty Information Element Separator * 1 PRV01 Provider Code < Provider Type Identifier Code> 1/3 Value is AT=Attending Provider Element Separator * 1 PRV02 Reference Identification Qualifier <Taxonomy Code Qualifier> 2/3 Value is PXC=Provider Taxonomy Code Element Separator * 1 PRV03 Reference Identification <Provider Taxonomy Code> 1/50 Value is the taxonomy Code associated with the NPI of the Attending Provider and registered with Louisiana Medicaid. In situations where a provider may have a single NPI associated with multiple LA Medicaid provider numbers, a tie- breaker such as taxonomy may be required for unique identification of the Medicaid provider ID. Use the same Taxonomy code that was registered with Louisiana Medicaid for the Attending Provider. 837 Institutional Companion Guide 28 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments Segment End ~ 1 324 2310A REF Attending Provider Secondary Identification Element Separator * 1 REF01 Reference Identification Qualifier G2 2/3 Value is G2 = Provider Louisiana Medicaid Number Element Separator * 1 REF02 Reference Identification <7-digit Louisiana Medicaid Provider ID> 1/50 Value is the 7-digit Medicaid provider number of an atypical provider who has not registered an NPI with Louisiana Medicaid. Otherwise, do not use this Loop. Segment End ~ 1 349 2310F Referring Provider Name If present, the Referring provider in this Loop applies to the entire claim, unless overridden at the Line level by the presence of Loop 2420D Element Separator * 1 350 NM101 Entity Identifier Code <Provider Identifier Qualifier Code> 2/3 Value is DN = Referring Provider Element Separator * 1 NM103 Name Last <Last name of Referring provider> 1/60 Value is the last name of the referring provider Element Separator * 1 NM104 Name First <First name of Referring Provider> 1/36 Value is the first name of the referring provider Element Separator * 1 837 Institutional Companion Guide 29 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 351 NM108 Identification Code Qualifier <Provider Identifier Qualifier Code> 1/2 Value is XX = National Provider Identifier Element Separator * 1 NM109 Identification Code <NPI of Referring Provider> 2/80 Value is the NPI registered with Louisiana Medicaid that corresponds to the Medicaid provider being reported in this Loop. The Referring Provider must be enrolled in LA. Medicaid. Segment End ~ 1 352 2310F REF Referring Provider Secondary Identification Use this Loop for atypical providers who do not have an NPI. Otherwise, do not use this Loop. Element Separator * 1 REF01 Reference Identification Qualifier G2 2/3 G2 = Provider Medicaid Number Element Separator * 1 REF02 Reference Identification <7-digit Louisiana Medicaid Provider ID> 1/50 Value is the 7-digit Medicaid provider number of an atypical provider who has not registered an NPI with Louisiana Medicaid. Segment End ~ 1 354 2320 SBR Other Subscriber Information Repeat if more than one other payer has previously processed the claim. Element Separator * 1 356 SBR09 Insurance Type Code 11,12,13,14,15,16, 17,AL,BL,CH,CI, DS,FI,HM,LM,TV, VA,ZZ 1/2 Do NOT use MC for this segment when reporting information about another payer or payers involved in this claim. Use MA when billing Medicare Advantage claims, Use one of the other codes for additional third party coverage. Segment End ~ 1 837 Institutional Companion Guide 30 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 358 2320 CAS Claim Level Adjustments Required if other payers are known to be involved in paying on this claim. May repeat up to 6 sets of CAS01/CAS02 groupings. Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. Use Loop 2320 only if claim level data is provided by the other payer. If claim line data is available it must be reported in Loop 2430. Element Separator * 1 CAS01 Claim Adjustment Group Code CO,CR,OA,PI,PR 1/2 Value is the code received from other payer reported in this Loop. When PR is used, include segments for Deductible, Coinsurance and/or Co-payment amounts as appropriate. Element Separator * 1 359 CAS02 Claim Adjustment Reason Code <Standard Claim Adjustment Reason Code> 1/5 Value is CARC code received from other payer reported in this Loop. Element Separator * 1 CAS03 Monetary Amount <Dollar Value of Adjustment> 1/18 Value is the amount of adjustment associated with CAS Code pairing Element Separator * 1 384 2330B NM1 Other Payer Name Add information here when another payer has processed the claim before it is sent to Louisiana Medicaid. Repeat Segment if more than one other payer has previously processed the claim. Element Separator * 1 837 Institutional Companion Guide 31 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments NM108 Identification Code Qualifier PI 1/2 Value is PI = Payer Identification Segment Separator * 1 385 NM109 Identification Code <Louisiana Medicaid Carrier Code> 6 Value is the 6-digit Louisiana Medicaid Carrier Code for the Payer identified in Loop 2320.The LA Medicaid TPL Carrier Code list can be found on lamedicaid.com under Forms/Files/User Manuals navigational link. Segment End ~ 1 423 2400 LX Service Line Number The service line number must begin with one and is incremented by 1 for each additional service line. This number can be useful for provider and practice management systems for matching to the electronic remittance advice 835 Transaction. Element Separator * 1 LX01 Assigned Number <Service Line Number> 1/6 Louisiana Medicaid will process and store up to 28 lines for Inpatient claims. Segment End ~ 1 424 2400 SV2 Institutional Service Line Required to specify line level information for institutional claims. Element Separator * 1 425 SV204 Unit or Basis of Measurement Code <Unit Qualifier Code> 2/2 Value is DA = Days or UN = Units. Element Separator * 1 428 SV205 Quantity <Service Unit Count> 1/4 The maximum length for Louisiana Medicaid for the quantity field is 4 whole numbers. Element Separator * 1 837 Institutional Companion Guide 32 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 2400 DTP Service Date Element Separator * 1 DTP01 Date/Time Qualifier < Qualifier Code> 3/3 Value is 472 = Service Date Element Separator * 1 DTP02 Date/Time Format Qualifier D8, RD8 2/3 Value is D8=CCYYMMDD for single date of service or RD8=CCYYMMDD- CCYYMMDD for range of dates Element Separator * 1 DTP03 Date Time Period <Date or Time Period> 1/35 Service Line Date(s) of service are required on all Outpatient and Home Health claims. Segment End ~ 1 452 2410 LIN Drug Identification A federal statue mandates that providers must report National Drug Code (NDC) information for all physician- administered drugs on LA Medicaid claims submissions. This requirement applies to both electronic and hardcopy claims. Providers are required to submit NDC information for the corresponding HCPCS code for physician- administered drugs. Claims must reflect the NDC from the label of the product administered. Element Separator * 1 LIN02 Product/Service ID Qualifier <Drug Code Qualifier> 2/2 Value is N4 = National Drug Code in 5-4-2 format. Element Separator * 1 837 Institutional Companion Guide 33 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments LIN03 Product/Service ID <NDC Code> 1/48 Value is the National Drug Code associated with the physician-administered drug identified in Loop 2400 SV202-2. Segment End ~ 1 452 2410 CTP Drug Quantity Quantity and Unit or Basis of Measurement Codes are required for claims for drugs to process correctly. Element Separator * 1 CTP04 Quantity <Units Administered> 1/10 Value is the quantity or actual units administered. The maximum quantity to be entered for LA Medicaid is seven whole numbers and three decimal places. Element Separator * 1 453 CTP05-01 Unit or Basis of Measurement Code F2, GE, ME, ML, UN 2/2 F2 = International Unit GR = Gram ME = Milligram ML = Milliliter UN = Unit Segment End ~ 1 2420C NM1 Rendering Provider Name If present, the rendering provider identified in this Loop applies to the Line Level and overrides the Attending Provider at the Claim Level in Loop 2310A. Element Separator * 1 NM101 Entity Identifier Code <Qualifier Code> 2/3 Value is 82 = Rendering Provider NM108 Identification Code Qualifier <Provider Identifier Qualifier Code> 1/2 Value is XX = National Provider Identifier Element Separator * 1 837 Institutional Companion Guide 34 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments NM109 Identification Code <National Provider Identification> 2/80 Value is the NPI registered with Louisiana Medicaid that corresponds to the Louisiana Medicaid Provider being reported in this Loop. If the provider is considered an atypical provider and has not registered an NPI with Louisiana Medicaid, continue to use Loop 2420C, REF 02 with qualifier G2 to provider the Louisiana Medicaid Provider ID. Segment End ~ 1 2420C REF Rendering Provider Secondary Identification Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider. Element Separator * 1 REF01 Reference Identification Qualifier G2 2/3 Value is G2 = Louisiana Medicaid 7- digit Provider Number. Element Separator * 1 REF02 Reference Identification <Louisiana Medicaid Provider Number> 1/7 If the Rendering Provider is an atypical provider who has not registered an NPI with Louisiana Medicaid, you may send the 7-digit legacy Medicaid Provider number in this Loop. Segment End ~ 471 2420D NM1 Referring Provider Name Required when this service line involves a referral and the referring provider differs from that reported at the claim level (loop 2310A). When billing for services for a Lock-In recipient, identify the Lock- In Physician. 837 Institutional Companion Guide 35 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments Element Separator * 1 NM101 Entity Identifier Code <Referring Provider Qualifier Code> 2/3 Value is DN = Referring Provider Element Separator * 1 NM103 Name Last <Referring Provider Last Name> 1/60 Value is the last name of the referring provider. Element Separator * 1 NM104 Name First <Referring Provider First Name> 1/35 Value is the first name of the referring provider. Element Separator * 1 473 NM108 Identification Code Qualifier <Provider Identifier Qualifier Code> 1/2 Value is XX = National Provider Identifier Element Separator * 1 NM109 Identification Code <NPI of Referring Provider> 2/80 Value is the NPI registered with Louisiana Medicaid that corresponds to the provider being reported in the Loop. The Referring Provider must be enrolled in Louisiana Medicaid. Segment End ~ 474 2420D REF Referring Provider Secondary Identification Required when this service line involves a referral and the referring provider differs from that reported at the claim level (loop 2310F). Do not use this Loop if Referring provider has an NPI. Element Separator * 1 REF01 Reference Identification	837_Institutional_Companion_Guide.pdf
for LA Medicaid is seven whole numbers and three decimal places. Element Separator * 1 453 CTP05-01 Unit or Basis of Measurement Code F2, GE, ME, ML, UN 2/2 F2 = International Unit GR = Gram ME = Milligram ML = Milliliter UN = Unit Segment End ~ 1 2420C NM1 Rendering Provider Name If present, the rendering provider identified in this Loop applies to the Line Level and overrides the Attending Provider at the Claim Level in Loop 2310A. Element Separator * 1 NM101 Entity Identifier Code <Qualifier Code> 2/3 Value is 82 = Rendering Provider NM108 Identification Code Qualifier <Provider Identifier Qualifier Code> 1/2 Value is XX = National Provider Identifier Element Separator * 1 837 Institutional Companion Guide 34 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments NM109 Identification Code <National Provider Identification> 2/80 Value is the NPI registered with Louisiana Medicaid that corresponds to the Louisiana Medicaid Provider being reported in this Loop. If the provider is considered an atypical provider and has not registered an NPI with Louisiana Medicaid, continue to use Loop 2420C, REF 02 with qualifier G2 to provider the Louisiana Medicaid Provider ID. Segment End ~ 1 2420C REF Rendering Provider Secondary Identification Required when the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider. Element Separator * 1 REF01 Reference Identification Qualifier G2 2/3 Value is G2 = Louisiana Medicaid 7- digit Provider Number. Element Separator * 1 REF02 Reference Identification <Louisiana Medicaid Provider Number> 1/7 If the Rendering Provider is an atypical provider who has not registered an NPI with Louisiana Medicaid, you may send the 7-digit legacy Medicaid Provider number in this Loop. Segment End ~ 471 2420D NM1 Referring Provider Name Required when this service line involves a referral and the referring provider differs from that reported at the claim level (loop 2310A). When billing for services for a Lock-In recipient, identify the Lock- In Physician. 837 Institutional Companion Guide 35 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments Element Separator * 1 NM101 Entity Identifier Code <Referring Provider Qualifier Code> 2/3 Value is DN = Referring Provider Element Separator * 1 NM103 Name Last <Referring Provider Last Name> 1/60 Value is the last name of the referring provider. Element Separator * 1 NM104 Name First <Referring Provider First Name> 1/35 Value is the first name of the referring provider. Element Separator * 1 473 NM108 Identification Code Qualifier <Provider Identifier Qualifier Code> 1/2 Value is XX = National Provider Identifier Element Separator * 1 NM109 Identification Code <NPI of Referring Provider> 2/80 Value is the NPI registered with Louisiana Medicaid that corresponds to the provider being reported in the Loop. The Referring Provider must be enrolled in Louisiana Medicaid. Segment End ~ 474 2420D REF Referring Provider Secondary Identification Required when this service line involves a referral and the referring provider differs from that reported at the claim level (loop 2310F). Do not use this Loop if Referring provider has an NPI. Element Separator * 1 REF01 Reference Identification Qualifier G2 2/3 Value is G2 = Louisiana Medicaid 7- digit Provider Number. Element Separator * 1 837 Institutional Companion Guide 36 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 475 REF02 Reference Identification <Louisiana Medicaid Provider Number> 1/7 If the Referring Provider is an atypical provider who has not registered an NPI with Louisiana Medicaid, you may send the 7-digit legacy Medicaid Provider number in this Loop. Segment End ~ 1 476 2430 SVD Line Adjudication Information Required when the claim has been previously adjudicated by payer identified in Loop ID- 2330B and this service line has payments and/or adjustments applied to it. Repeat if multiple payers involved. Element Separator * 1 SVD01 Identification Code <Louisiana Medicaid Carrier Code> 2/80 Value is the 6-digit Louisiana Medicaid Carrier Code. Number should match NM109 in Loop 2330B identifying the Other Payer. The LA Medicaid TPL Carrier Code list can be found on lamedicaid.com under Forms/Files/User Manuals navigational link. Element Separator * 1 477 SVD02 Monetary Amount <Service Line Paid Amount> 1/10 Value is the amount Other Payer paid for this service line. Element Separator * 1 837 Institutional Companion Guide 37 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 480 2430 CAS Line Adjustment Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. Providers are to enter the information as received on the remittance from the Other Payer. Use Loop 2430 only if Line Level data is provided by the other payer. 482 CAS01 Claim Adjustment Group Code CO, OA, PI, PR 1/2 When using Value of PR, include amounts for Deductible, Co-insurance and/or Co-Pay as appropriate. Element Separator * 1 CAS02 Claim Adjustment Reason Code <Claim Adjustment Reason Code> 1/5 Value is the CARC code received from the Other Payer for the associated service. Element Separator * 1 486 CAS03 Monetary Value Adjustment Amount 1/8 Value is the monetary adjustment amount received from the Other Payer for the associated service. Element Separator * 1 488 TRAILER SE Transaction Set Trailer Element Separator * 1 SE01 Transaction Segment Count <Number> 1/10 Value is the total number of Segments included. Element Separator * 1 SE02 Transaction Set Control Number <Identifying Control Number> 4/9 Unique control number and must be identical in ST02 and SE02. Segment End ~ 1 837 Institutional Companion Guide 38 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments C.9 TRAILER GE Functional Group Trailer Element Separator * 1 GE01 Number of Transaction <Number> 1/6 Value is the number of Transaction sets included. Element Separator * 1 GE02 Group Control Number <Sender Assigned Number> 1/9 Value must be identical to value in GS06. Segment End ~ 1 C.10 TRAILER IEA Interchange Control Trailer Element Separator * 1 IEA01 Number of Functional Groups <Number> 1/5 Value is number of Functional Groups included. Element Separator * 1 IEA02 Interchange Control Number <Sender Assigned Number> 9/9 Value must be identical to value in ISA13. Segment End ~ 1 837 Institutional Companion Guide 39 THIS PAGE INTENTIONALLY LEFT BLANK 837 Institutional Companion Guide 40 Appendices Appendix A – Implementation Checklist This appendix contains all necessary steps for submitting/receiving electronic transactions with Louisiana Medicaid. • Providers must register to become a Trading Partner (TP) and be assigned a TP Submitter number. • Trading Partners must sign a Trading Partner Agreement. o Trading Partner must contact the EDI Help Desk by submitting an email to [email protected] or calling (225) 216-6303 to make arrangements for testing and approval to submit production transactions. • Trading Partners must submit two (2) test files of a particular transaction type, with no minimum number of transactions within each file, and have no failures or rejections to be approved to submit production transactions. The test claims should be representative of the type of service you will be providing. • Confirm all NPIs used in testing are valid for Louisiana Medicaid and if zip-code or taxonomy are needed as tie-breakers. • Review all reports produced by the Gainwell EDI test system. • Once TP receives email approval from the EDI Department, may begin submitting claim files to Production environment. Appendix B – Business Scenarios and Claim/Encounter Example This section describes a few special billing scenarios and transaction examples follow. The first scenario describes the electronic billing to Medicaid for medical services of dual-eligible recipients (i.e., eligible for both Medicare and Medicaid). In situations where Medicare has denied a service which may be covered by Medicaid, the claim may be billed directly to Medicaid. This type of claim will be submitted as a Medicaid claim and not a Medicare crossover. In the past, this type of claim was mandated to be billed hardcopy with the Medicare EOBs attached. The correct placement of the 837I Segments related to Medicare third party information is shown in the scenario 1 examples. The Louisiana Department of Health has identified the unique Louisiana Carrier code for NM109 in the 2330B Loop when reporting the Medicare information as MOL001. The second scenario describes claim examples for billing Medicare Advantage claims electronically. The third scenario describes specific information needed for submitting Subrogation encounters. Only Managed Care Trading Partners are permitted to bill Subrogation type encounters. When a Managed Care Entity (MCE) Member Linkage is retroactively removed and the Member retains Louisiana Medicaid eligibility for the same period, the MCE the Member was linked to may have paid claims for the Member during that period. Retroactive disenrollment may be performed by the Enrollment Broker due to retroactive Medicare coverage changes, the Member opting out of Medical MCE coverage, retroactive linkage of the Member to a Long-Term Care facility or the Program for the All-Inclusive Care for the Elderly (PACE) program. 837 Institutional Companion Guide 41 Any claims already billed to and paid by the MCE during this period would then be excused from the MCEs scope of responsibility. The MCE would be entitled to void any such claims and request the billing provider resubmit their claims to Gainwell for Fee For Service (FFS) Medicaid adjudication and payment. Subrogation outlines the means by which MCEs may submit electronic transactions as a remedy to the covering plan, and to mitigate provider abrasion created by having the biller’s previous payment recovered and requesting them to rebill elsewhere. Medicaid Subrogation is a process recognized by CMS and ANSI allowing reimbursement between Payers. Subrogation will allow an MCE previously identified as the payer of last resort for a Member to request reimbursement directly from Gainwell on the basis of encounters previously reported for any such claims paid to the billed provider. This solution provides for direct payment to the MCE without placing any burden of action on the original billing provider. Do not Void the original encounter that is being subrogated. Subrogation requires an original Approved encounter be on file. Rejected or Voided encounters may not be subrogated at this time. 837 Institutional Companion Guide 42 a. Scenario 1 - CLAIMs FOR DUAL MEDICAID/MEDICARE ELIGIBLE WHEN DENIED BY MEDICARE The following claim examples are presented as a tool to assist with proper build of electronic 837I for a Dual eligible recipient with Medicare denial information. This example does not represent a complete claim; it gives emphasis to the information needed for identifying the Medicare denial reason(s). Example 1 837I---Inpatient Claim Example for Bill Type 11x (Part A benefits denied by Medicare for Dual Eligible Recipient) NM1IL1SMITHTOM***MI1112233334444~ N3500 MAIN STREET~ N4BATON ROUGELA70809 DMGD819570101M~ NM1PR2LOUISIANA MEDICAID****PILA-DHH-MEDICAID~ N34456 SOUTH SHORE BLVD~ N4BATON ROUGELA444440056~ CLM264077779129*11:A:1AYY~ DTP096TM1625~ DTP434RD820150114-20150118~ DTP435DT201501140725~ CL14501~ REFEAA0012345~ HIBK:V3001~ HIBJ:V3001~ HIBF:7728:::::::N~ HIBE:02:::0BE:80:::4~ HIBG:C1~ NM1711KILDAIREROSALYN***XX1234567890~ LOOP 2320 SBRP18MEDICARE PART A**MA~ Must identify as Medicare Part A CASPR2589129~ (Service not covered when person is incarcerated) AMTD0~ AMTEAF9129~ OI*YY~ LOOP 2330B NM1PR2Medicare Part A****PIMOL001~ Must use this Carrier Code N3PO BOX 12345~ N4Baton RougeLA70808~ DTP573D820150527~ Loop 2400 LX1~ SV201103280DA4~ LX2~ SV20250200UN2~ LX3~ SV203011615UN9~ LX4~ SV203111133UN1~ LX5~ SV204711147UN1~ LX6~ SV206361214UN2~ - --------continue transaction 837 Institutional Companion Guide 43 Example 2: 837I Outpatient Claim example for Bill Type 13x (Part A benefits denied by Medicare for Dual Eligible Recipient.) NM1IL1SMITHJERRY**MI3334455556666~ N3600 MAIN STREET~ N4BATON ROUGELA70809 DMGD819590101M~ NM1PR2LOUISIANA MEDICAID****PILA-DHH-MEDICAID~ N34456 SOUTH SHORE BLVD~ N4BATON ROUGELA444440056~ CLM264077771040*13:A:1AYY~ DTP096TM1625~ DTP434D820150114~ DTP435DT201501140725~ CL14501~ REFEAA0012345~ HIBK:V3001~ HIBJ:V3001~ HIBF:7728:::::::N~ HIBE:02:::0BE:80:::4~ HIBG:C1~ NM1711KILDAIREBEN***XX1234567890~ LOOP 2320 SBRP18MEDICARE PART A**MA~ Must identify as Medicare Part A AMTD0~ OIYY~ LOOP 2330B NM1PR2Medicare Part A****PIMOL001~ Must use this Carrier Code N3PO BOX 12345~ N4Baton RougeLA70808~ DTP573D820150527~ Loop 2400 LX1~ SV10250200UN2~ DTP472D820140114 Loop 2430 SVDMOL0010*02502~ CASPR51200~ (These are non-covered services because this is a pre-existing condition) DTP573D820150301 AMTEAF200~ LX2~ SV10320HC:73060:RT406UN1~ DTP472D820140114 SVDMOL0010HC:73060:RT03201~ CASPR51406~ (These are non-covered services because this is a pre-existing condition) DTP573D820150301 AMTEAF406~ 837 Institutional Companion Guide 44 LX3~ SV10450HC:99283:25434UN1~ DTP472D820140114 SVDMOL0010HC:99283:2504501~ CASPR51434~ (These are non-covered services because this is a pre-existing condition) DTP573D820150301 AMTEAF434~ - --------continue transaction b. Scenario 2 - CLAIMS FOR RECIPIENTS WITH MEDICARE ADVANTAGE COVERAGE The following claim examples are presented as a tool to assist with proper build of electronic 837I for a Dual eligible recipient with Medicare Advantage coverage. These examples do not represent a complete claim; it gives emphasis to the information needed for identifying the Medicare Advantage Carrier Code and processing details. Example 1 837I ---- Inpatient Claim Example for Bill	837_Institutional_Companion_Guide.pdf
submit electronic transactions as a remedy to the covering plan, and to mitigate provider abrasion created by having the biller’s previous payment recovered and requesting them to rebill elsewhere. Medicaid Subrogation is a process recognized by CMS and ANSI allowing reimbursement between Payers. Subrogation will allow an MCE previously identified as the payer of last resort for a Member to request reimbursement directly from Gainwell on the basis of encounters previously reported for any such claims paid to the billed provider. This solution provides for direct payment to the MCE without placing any burden of action on the original billing provider. Do not Void the original encounter that is being subrogated. Subrogation requires an original Approved encounter be on file. Rejected or Voided encounters may not be subrogated at this time. 837 Institutional Companion Guide 42 a. Scenario 1 - CLAIMs FOR DUAL MEDICAID/MEDICARE ELIGIBLE WHEN DENIED BY MEDICARE The following claim examples are presented as a tool to assist with proper build of electronic 837I for a Dual eligible recipient with Medicare denial information. This example does not represent a complete claim; it gives emphasis to the information needed for identifying the Medicare denial reason(s). Example 1 837I---Inpatient Claim Example for Bill Type 11x (Part A benefits denied by Medicare for Dual Eligible Recipient) NM1IL1SMITHTOM***MI1112233334444~ N3500 MAIN STREET~ N4BATON ROUGELA70809 DMGD819570101M~ NM1PR2LOUISIANA MEDICAID****PILA-DHH-MEDICAID~ N34456 SOUTH SHORE BLVD~ N4BATON ROUGELA444440056~ CLM264077779129*11:A:1AYY~ DTP096TM1625~ DTP434RD820150114-20150118~ DTP435DT201501140725~ CL14501~ REFEAA0012345~ HIBK:V3001~ HIBJ:V3001~ HIBF:7728:::::::N~ HIBE:02:::0BE:80:::4~ HIBG:C1~ NM1711KILDAIREROSALYN***XX1234567890~ LOOP 2320 SBRP18MEDICARE PART A**MA~ Must identify as Medicare Part A CASPR2589129~ (Service not covered when person is incarcerated) AMTD0~ AMTEAF9129~ OI*YY~ LOOP 2330B NM1PR2Medicare Part A****PIMOL001~ Must use this Carrier Code N3PO BOX 12345~ N4Baton RougeLA70808~ DTP573D820150527~ Loop 2400 LX1~ SV201103280DA4~ LX2~ SV20250200UN2~ LX3~ SV203011615UN9~ LX4~ SV203111133UN1~ LX5~ SV204711147UN1~ LX6~ SV206361214UN2~ - --------continue transaction 837 Institutional Companion Guide 43 Example 2: 837I Outpatient Claim example for Bill Type 13x (Part A benefits denied by Medicare for Dual Eligible Recipient.) NM1IL1SMITHJERRY**MI3334455556666~ N3600 MAIN STREET~ N4BATON ROUGELA70809 DMGD819590101M~ NM1PR2LOUISIANA MEDICAID****PILA-DHH-MEDICAID~ N34456 SOUTH SHORE BLVD~ N4BATON ROUGELA444440056~ CLM264077771040*13:A:1AYY~ DTP096TM1625~ DTP434D820150114~ DTP435DT201501140725~ CL14501~ REFEAA0012345~ HIBK:V3001~ HIBJ:V3001~ HIBF:7728:::::::N~ HIBE:02:::0BE:80:::4~ HIBG:C1~ NM1711KILDAIREBEN***XX1234567890~ LOOP 2320 SBRP18MEDICARE PART A**MA~ Must identify as Medicare Part A AMTD0~ OIYY~ LOOP 2330B NM1PR2Medicare Part A****PIMOL001~ Must use this Carrier Code N3PO BOX 12345~ N4Baton RougeLA70808~ DTP573D820150527~ Loop 2400 LX1~ SV10250200UN2~ DTP472D820140114 Loop 2430 SVDMOL0010*02502~ CASPR51200~ (These are non-covered services because this is a pre-existing condition) DTP573D820150301 AMTEAF200~ LX2~ SV10320HC:73060:RT406UN1~ DTP472D820140114 SVDMOL0010HC:73060:RT03201~ CASPR51406~ (These are non-covered services because this is a pre-existing condition) DTP573D820150301 AMTEAF406~ 837 Institutional Companion Guide 44 LX3~ SV10450HC:99283:25434UN1~ DTP472D820140114 SVDMOL0010HC:99283:2504501~ CASPR51434~ (These are non-covered services because this is a pre-existing condition) DTP573D820150301 AMTEAF434~ - --------continue transaction b. Scenario 2 - CLAIMS FOR RECIPIENTS WITH MEDICARE ADVANTAGE COVERAGE The following claim examples are presented as a tool to assist with proper build of electronic 837I for a Dual eligible recipient with Medicare Advantage coverage. These examples do not represent a complete claim; it gives emphasis to the information needed for identifying the Medicare Advantage Carrier Code and processing details. Example 1 837I ---- Inpatient Claim Example for Bill Type 11x with Medicare Advantage NM1IL1SMITHTOM***MI1112233334444~ N3500 MAIN STREET~ N4BATON ROUGELA70809 DMGD819570101M~ NM1PR2LOUISIANA MEDICAID****PILA-DHH-MEDICAID~ N34456 SOUTH SHORE BLVD~ N4BATON ROUGELA444440056~ CLM2640777728473.64*11:A:1AYY~ DTP096TM1625~ DTP434RD820150515-20150520~ DTP435DT201505150725~ CL11101~ REFEAA0012345~ HIBK:5770~ HIBJ:570~ HIBF:4561:::::::N~ HIBE:02:::0BE:80:::5~ HIBG:C1~ NM1711KILDAIREROSALYN***XX1234567890~ LOOP 2320 SBRP18MEDICARE ADVANTAGE PART A**MA~ MUST use code MA for Medicare Advantage Part A CASCO4518320.55~ CASPR2875~ AMTD9278.09~ AMTEAF9129~ OIYY~ 837 Institutional Companion Guide 45 LOOP 2330B NM1PR2HUMANA****PIH19510~ Must use the Medicare Advantage Plan Louisiana Carrier Code N3PO BOX 12345~ N4BATON ROUGELA70808~ DTP573D820150603~ Loop 2400 LX1~ SV201103665DA5~ LX2~ SV20250 2637.64UN110~ LX3~ SV20270 1100UN20~ LX4~ SV20300 66UN6~ LX5~ Thru LXnn - --------continue transaction Example 2 837I---Outpatient Claim example for Bill Type 13x with Medicare Advantage NM1IL1SMITHJERRY**MI3334455556666~ N3600 MAIN STREET~ N4BATON ROUGELA70809 DMGD819590101M~ NM1PR2LOUISIANA MEDICAID****PILA-DHH-MEDICAID~ N34456 SOUTH SHORE BLVD~ N4BATON ROUGELA444440056~ CLM264077771377*13:A:1AYY~ DTP096TM1625~ DTP434D820150323~ DTP435DT201503230825~ CL11101~ REFEAA0012345~ HIBK:4019~ HIBJ:71941~ HIBF:2720:::::::N~ NM1711KILDAIREBEN**XX1234567890~ LOOP 2320 SBRP18MEDICARE PART A**MA~ MUST use code MA for Medicare Advantage Part A AMTD236.73~ OIYY~ 837 Institutional Companion Guide 46 LOOP 2330B NM1PR2HUMANA****PIH19510~ Must use the Louisiana Medicare Advantage Carrier Code N3PO BOX 12345~ N4BATON ROUGELA70808~ DTP573D820150402~ Loop 2400 LX1~ SV202502UN1~ DTP472D820150323~ LX2~ SV20320HC:73030:RT219UN1~ DTP472D820150323~ LX3~ SV20450HC:99284:251113UN1~ DTP472D820150323~ LX4~ SV20730HC:9300543UN1~ DTP472D820150323~ Loop 2430 LX1 SVDH195100*02502~ CASCO452~ DTP573D820150323 LX2~ SVDH195100HC:73030:RT03201~ CASCO45219~ DTP573D820150323 LX3~ SVDH19510236.73HC:99284:2504501~ CASPR365~ CASCO2534.83~45806.44~ DTP573D820150323 LX4~ SVDH195100HC:9300507301~ CASCO4543~ DTP573D820150323~ - --------continue transaction 837 Institutional Companion Guide 47 Example 3 837I---Inpatient Claim example for Bill Type 11x Medicare Advantage and Other Third Party Coverage NM1IL1SMITHTOM***MI1112233334444~ N3500 MAIN STREET~ N4BATON ROUGELA70809 DMGD819570101M~ NM1PR2LOUISIANA MEDICAID****PILA-DHH-MEDICAID~ N34456 SOUTH SHORE BLVD~ N4BATON ROUGELA444440056~ CLM2640777728473.64*11:A:1AYY~ DTP096TM1625~ DTP434RD820150515-20150520~ DTP435DT201505150725~ CL11101~ REFEAA0012345~ HIBK:5770~ HIBJ:570~ HIBF:4561:::::::N~ HIBE:02:::0BE:80:::5~ HIBG:C1~ NM1711KILDAIREROSALYN***XX1234567890~ LOOP 2320 SBRP18MEDICARE ADVANTAGE PART A**MA~ MUST Use code MA for Medicare Advantage Part A CASCO4518320.55~ CASPR2875~ AMTD9278.09~ AMTEAF9129~ OIYY~ LOOP 2330B NM1PR2HUMANA****PIH19510~ Must use the Medicare Advantage Plan Louisiana Carrier Code N3PO BOX 12345~ N4BATON ROUGELA70808~ DTP573D820150603~ LOOP 2320 SBRS18AARP***CI~ Use code CI for Other Private Third Party Coverage CASCO4518320.55~ CASOA239278.09~ AMTD875~ AMTEAF9129~ OIYY~ LOOP 2330B NM1PR2AARP Supplement****PI270500~ Must use the appropriate LA Medicaid Carrier Code N3PO BOX 12345~ N4BATON ROUGELA70808~ DTP573D820150603~ 837 Institutional Companion Guide 48 Loop 2400 LX1~ SV201103665DA5~ LX2~ SV20250 2637.64UN110~ LX3~ SV20270 1100UN20~ LX4~ SV20300 66UN6~ Thru LXnn -------- continue transaction c. Scenario 3 – ENCOUNTERS FOR SUBROGATION The following encounter example is presented as a tool to assist with properly building an 837I for Subrogation. This example does not represent a complete claim; it gives emphasis to the information needed for identifying the encounter as Subrogation. This scenario applies only to Managed Care Trading Partners. Only Managed Care Trading Partners are permitted to bill using Transaction Code 31. See Appendix D for more information. BHT – Beginning of Hierarchical Transaction BHT0019000275453499000120231110130010 31~ Must use Transaction Type Code 31 LOOP 2010AC NM1PE2MCE ORGANIZATION NAME***PI9999999999~ Must include LOOP 2010AC N3999 STREET ADDRESS~ This is the Primary Payer Information N4CITYLA999999999~ REFEI999999999~ LOOP 2300 In Loop ID-2300 data element CLM01, enter the Gainwell assigned CLM4275127042400500**11:A:7YA ICN number rather than the Provider's Patient Control Number. Y\|~ In element CLM05-3 use Claim Frequency Type Code 7: Debit or Replacement adjustment. LOOP 2320 In Loop ID-2320 include all the required segments/elements SBRT18***MC~ that indicate Gainwell's adjudication of the original encounter. ... AMTD411~ AMT02 represents the amount Gainwell reported paid. LOOP 2330B NM1PR2LOUISIANA MEDICAID****PI LA-DHH-MEDICAID~ N4BATON ROUGELA70809 DTP573D820150527~ In Loop ID-2330B, enter Gainwell's information. 837 Institutional Companion Guide 49 Appendix C - Change Summary This appendix will contain a summary of any changes made to this version of the 837I Health Care Claim Companion Guide after the initial release. Ver. Date Author Action/Summary of Changes Loop/Segment 1.0 01/01/2018 Molina Initial Document in CAQH/CORE Master Companion Guide required standard format. Included in this initial release is new information regarding billing for Medicare Advantage claims. Section 4.4.3; Section 10-Segment SBR09; Appendix B Scenario 2 examples 1.2 04/27/2018 Molina Clarification on Medicare Advantage; Claim examples in Appendix B. Loop 2330/SBR09 1.3 02/06/2019 DXC Removed comments regarding # of lines for Outpatient claims. Loop 2400/LX01 1.4 2/23/2024 Gainwell Updated Appendix B Scenario 3. Loop 2300, 2320/2040, 2339B 1.5 10/09/2024 Gainwell Revised the Preface to provide a link to the 5010 EDI General Companion Guide. Added link to the 5010 EDI General Companion Guide to 1.1. Corrected the first paragraph of Appendix B for usage issues. Scenario 3 of Appendix B was added (subrogation). Re-designed document for paging issues. Corrected email addresses and links as needed. Appendix D (FAQs) removed. Appendix E renamed Appendix D and sample forms converted to links. n/a n/a n/a n/a n/a n/a n/a 1.6 1/14/2025 Gainwell Revised Appendix B Scenario 3. n/a 837 Institutional Companion Guide 50 Appendix D - Trading Partner Agreements (TPA) This appendix contains links to the forms required for electronic billing or election to receive an electronic remittance (835) for Louisiana Medicaid providers. There are separate forms for an individual enrollment and an entity/business enrollment. Links to the forms are provided below. EDI Contract and Power of Attorney for Individual: https://www.lamedicaid.com/Provweb1/Provider_Enrollment/EDI%20Individuals.pdf EDI Contract and Power of Attorney for Entity/Business: https://www.lamedicaid.com/Provweb1/Provider_Enrollment/EDI%20Entities-Businesses.pdf Completed forms are to be sent to Gainwell Provider Enrollment Unit, PO Box 80159, Baton Rouge, LA 70898- 0159.	837_Institutional_Companion_Guide.pdf
HIPAA Transaction Standard Companion Guide Healthcare Claim Payment/Advice ASC X12N 835 Version 005010X221A1 for State of Idaho MMIS Date of Publication: 02/29/2024 Document Number: TL419 Version: 11.0 Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page ii Revision History Version Date Author Action/Summary of Changes 1.0 07/01/2011 Molina Initial document 1.1 09/09/2013 Molina Modified to conform to CAQH/CORE standards 1.2 11/11/2013 Molina Updated with DHW requested changes 1.3 01/14/2014 Molina Changed the Data Flow Diagram in Section 4, and added information about Web Services in Section 4 2.0 01/31/2014 TQD DHW approved 1/27/2014 2.1 04/28/2014 J Phillips Added information about sending acknowledgements via Upload and VAN in Section 4 Connectivity with the Payer/Communications Process Flows per CR 35250 3.0 05/14/2014 TQD DHW validated 5/5/2014 3.1 05/20/2015 M McFadden Semi-annual review performed – made changes 3.2 05/26/2015 Hope McCain Removed references to retired TPA user guides. 4.0 06/15/2015 TQD DHW validated 6/10/2015 4.0 12/22/2015 D Greer Semi-annual review – no changes 4.0 5/26/2016 J Phillips Semi-annual review – no changes 4.1 12/19/2016 J Richardson Semi-annual review – remove secured FTP information and replace with VAN 5.0 1/18/2017 TQD DHW validated 1/12/2017 5.1 6/7/2017 Douglas Greer Semi-annual review – minor corrections 6.0 7/27/2017 TQD DHW validated changes 7/27/17 6.1 8/15/2017 Hope McCain Updated for TPA upgrade 6.2 11/22/2017 Hope McCain Additional updates based on State review 7.0 12/1/2017 TQD DHW validated changes 11/30/17 7.0 6/21/2018 J Richardson Semi-annual review – no changes 7.1 10/5/2018 M Zampierin Removed Molina reference and replaced with DXC Technology 7.1 11/27/2018 Jimmy Phillips Semi-annual review – no changes 7.1 3/1/2019 Jimmy Phillips Semi-annual review – no changes 7.1 3/29/2019 Cathy Lavacchia Semi-annual review – no changes 7.1 11/27/2019 Jimmy Phillips Semi-annual review – no changes 7.2 03/10/2020 Cathy Lavacchia Changed for Rebranding CR 58031 8.0 03/30/2020 TQD Finalized per DHW validated changes. 8.0 4/22/2021 Douglas Greer Semi-annual review – no changes 8.1 11/22/2021 Jen Richardson CMS semi-annual review, no content updates. Rebranding changes only. Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page iii Version Date Author Action/Summary of Changes 9.0 01/21/2022 TQD Finalized for publishing after rebranding 9.0 06/03/2022 Jimmy Phillips Reviewed for semi-annual; no updates necessary. 9.1 08/24/2022 Myranda Payne Clarified Register link location in section 2.2 Trading Partner Registration 10.0 09/30/2022 TQD Finalized per DHW validated changes. 10.0 11/23/2022 Jimmy Phillips Reviewed for semi-annual; no updates necessary. 10.1 05/24/2023 Kelsey Nielsen Changed the sentence "FTP though a secure, dedicated VAN connection." to "FTP through a secure, dedicated VAN connection." 10.2 11/16/2023 Kelsey Nielsen Semi-annual review; Grammatical corrections 10.3 01/25/2024 Jimmy Phillips Changed for Gainwell rebranding project CR 76444 11.0 02/29/2024 TQD Finalized per DHW validated changes. © 2020-2024 Gainwell Technologies Company. All rights reserved. Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page iv Table of Contents Introduction ........................................................................................................ 1 1.1. Scope ........................................................................................................... 2 1.2. Overview ...................................................................................................... 2 1.3. References .................................................................................................... 2 1.4. Additional Information .................................................................................... 2 Getting Started .................................................................................................... 3 2.1. Working with Gainwell Technologies ................................................................ 3 2.2. Trading Partner Registration ............................................................................ 3 2.3. Certification and Testing Overview .................................................................... 3 Testing with the Payer .......................................................................................... 3 Connectivity with the Payer/Communications Process Flows ...................................... 3 4.1. Process Flows ................................................................................................ 4 4.2. Transmission Administrative Procedures ........................................................... 5 4.3. Re-Transmission Procedure ............................................................................. 5 4.4. Communication Protocol Specifications ............................................................. 5 4.5. Passwords ..................................................................................................... 6 Contact Information ............................................................................................. 6 5.1. Gainwell Technologies EDI Helpdesk and EDI Technical Assistance ....................... 6 5.2. Provider Service Number ................................................................................ 6 5.3. Applicable Websites/E-mail .............................................................................. 7 Control Segments and Envelopes .............................................................................. 7 6.1. Delimiters ..................................................................................................... 7 6.2. ISA-IEA ........................................................................................................ 7 6.3. GS-GE .......................................................................................................... 7 6.4. ST-SE ........................................................................................................... 7 Payer-Specific Business Rules and Limitations ......................................................... 8 Acknowledgments and/or Reports .......................................................................... 8 8.1. Report Inventory (Not Sent for 835 Transactions) ............................................. 8 Trading Partner Agreements .................................................................................. 8 Transaction Specific Information ......................................................................... 8 Appendices ..................................................................................................... 22 Appendix A. Implementation Checklist ..................................................................... 22 Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 1 of 22 Introduction This section describes how the 5010 X12 Type 3 Technical Reports (TR3) adopted under HIPAA will be detailed using a table. The tables contain a row for each segment where Gainwell Technologies has something additional, over and above the information in the TR3. That information can: • Limit the repeat of loops or segments • Limit the length of a simple data element • Specify a sub-set of the TR3s internal code listings • Clarify the use of loops, segments, composite and simple data elements • Specify any other information tied directly to a loop, segment, composite, or simple data element pertinent to trading electronically with Gainwell Technologies In addition to the row for each segment, one or more additional rows are used to describe Gainwell Technologies' usage for composite and simple data elements and any other information. Notes and comments should be placed at the deepest level of detail. For example, a note about a code value should be placed on a row specifically for that code value, not in a general note about the segment. The following table specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides. Page # Loop ID Referenc e Name Codes Length Notes/Comments 193 2100C NM1 Subscriber Name This row type always indicates that a new segment has begun. It is always shaded at 10%, and notes or comments about the segment go in this cell. 195 2100C NM109 Subscriber Primary Identifier 15 This row type exists to limit the length of the specified data element. 196 2100C REF Subscriber Additional 197 2100C REF01 Reference Identification Qualifier 18, 49, 6P, These are the only codes transmitted by Gainwell MS Healthcare. Plan Network Identification Number N6 This row type exists when a note for a particular code value is required. For example, this note may say that value N6 is the default. Not populating the first 3 columns makes it clear that the code value belongs to the row immediately above it. 218 2110C EB Subscriber Eligibility or Benefit 231 2110C EB13-1 Product/Service ID Qualifier AD This row illustrates how to indicate a component data element in the Reference column and specify that only one code value is applicable. Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 2 of 22 1.1. Scope This companion guide documents the transaction type listed below and further defines situational and required data elements for processing the 835 healthcare claim payment advice for programs administered by Idaho Medicaid. This document is not the complete EDI transaction format specifications. The complete EDI 835 transaction format can be found in the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Health Care Claim Payment/Advice (835), as noted in the References section below. • Healthcare Claim Payment/Advice ASC X12N 835 (005010X221) • Addenda Healthcare Claim Payment Advice ASC X12N 835 (005010X221A1) 1.2. Overview Data elements, segments, and loops not included in this guide are not used for processing transactions by Idaho Medicaid but will still be sent if the information is required for compliance with the ASC X12N version 5010A1 format. See the References section below. 1.3. References Please refer to the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Health Care Claim Payment/Advice (835) for information not supplied in this document, such as code lists, definitions, and edits. This TR3 Guide can be obtained from the Washington Publishing Company. Their website is https://www.wpc-edi.com. 1.4. Additional Information The CCD+ and X12 835 TR3 TRN Segment were adopted together as the Federal Healthcare EFT Standards in CMS-0024-IFC: Administrative Simplification: Adoption of Standards for Health Care Electronic Funds Transfers (EFTs) and Remittance Advice. • The 835 Healthcare Claim Payment Advice allows automated matchup of claims payment data sent to the Receiver from Idaho Medicaid using computer software. • The delivery and use of the 835 Healthcare Claim Payment continues to increase compliance with HIPAA-adopted administrative transactions and encourages entities to use this infrastructure eligibility and claim status. • Adoption of the 835 Healthcare Claim Payment Advice simplifies and standardizes information to match the payment to the remittance advice detail, thereby decreasing confusion around electronic funds transfer (EFT) and ERA. • Consistent and uniform rules enable providers to match and process both the EFT payment and the v5010 X12 835 and help mitigate: o Unnecessary manual provider follow-up o Faulty electronic secondary billing o Inappropriate write-offs of billable charges o Incorrect billing of patients for co-pays and deductibles o Posting delays • And provide for: o Less staff time spent on phone calls and websites o Increased ability to conduct targeted follow-up with health plans and/or patients o More accurate and efficient payment of claims If you do not already receive the 835 Healthcare Claim Payment Advice (electronically), please contact the EDI Help Desk today at 1 (866) 686-4272 and select option 2 when prompted for more information. Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 3 of 22 Getting Started 2.1. Working with Gainwell Technologies Please visit https://www.idmedicaid.com and click on the Companion Guides link under Reference Material to view the latest versions of this and other X12 Companion Guides. For information on how to use the portal once registered as a trading partner, click the User Guides link under Reference Material. For any questions or to begin testing, contact the Gainwell Technologies EDI Helpdesk at 1 (866) 686-4272 option 2, or e-mail us at [email protected]. 2.2. Trading Partner Registration A Trading Partner Account (TPA) is any entity with which Gainwell Technologies exchanges electronic data. The term electronic data is not limited to HIPAA X12 transactions. Gainwell Technologies will assign trading partner IDs to support the exchange of X12 EDI transactions for providers, billing agencies and clearinghouses, and other health plans. To become a trading partner and get your trading partner ID, please visit our website at https://www.idmedicaid.com and click the Register link in the upper right-hand corner of the screen. You may also contact us at 1 (866) 686-4272, option 2. 2.3. Certification and Testing Overview All TPA must be authorized to submit production EDI transactions. Authorization is granted on a per-transaction basis. For example, a trading partner may be certified to submit 837P professional claims but not certified to submit 837I institutional claim files. Any TPA may submit test EDI transactions. The Usage Indicator, element 15 of the Interchange Control Header (ISA) of an X12 file, indicates if a file is test or production. Testing with the Payer Trading partners must submit three test files of a particular transaction type, with a minimum of fifteen transactions within each file, and have no failures or rejections to become certified for production. Users will be notified via e-mail and the Trading Partner Status page of the Health PAS website when testing for a particular transaction has been completed. The Trading Partner Status page is found by logging into your trading partner account on the Health PAS website (https://www.idmedicaid.com), hovering over the Account Management tab, and then clicking User Status. Detailed instructions for retrieving and interpreting HIPAA validation acknowledgments may be found on the Health PAS website under Companion Guides in the 5010 – Appendix A Vendor Specs document. Connectivity with the Payer/Communications Process Flows Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 4 of 22 4.1. Process Flows Below is the TPA Portal Services Process Flow (Retrieval of an 835 using the TPA Portal Services). Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 5 of 22 Below is the CAQH Web Services Process Flow (Generic Batch Retrieval Request of an 835). 4.2. Transmission Administrative Procedures X12 files (including an acknowledgment of an 835) can be uploaded via the Health PAS website File Exchange X12 Upload. 835 Healthcare Claim Payment Advice transaction files, acknowledgments, and responses to transactions submitted via the Health PAS website can be accessed by selecting Responses under the File Exchange menu. Trading Partners who have established a VAN connection and submitted X12 transactions via the VAN connection may retrieve acknowledgments and responses from their designated VAN Pickup locations. A VAN connection is a secure VPN connection through which X12 files are transferred	CAQH 5010 835 Companion Guide (1).pdf
and other X12 Companion Guides. For information on how to use the portal once registered as a trading partner, click the User Guides link under Reference Material. For any questions or to begin testing, contact the Gainwell Technologies EDI Helpdesk at 1 (866) 686-4272 option 2, or e-mail us at [email protected]. 2.2. Trading Partner Registration A Trading Partner Account (TPA) is any entity with which Gainwell Technologies exchanges electronic data. The term electronic data is not limited to HIPAA X12 transactions. Gainwell Technologies will assign trading partner IDs to support the exchange of X12 EDI transactions for providers, billing agencies and clearinghouses, and other health plans. To become a trading partner and get your trading partner ID, please visit our website at https://www.idmedicaid.com and click the Register link in the upper right-hand corner of the screen. You may also contact us at 1 (866) 686-4272, option 2. 2.3. Certification and Testing Overview All TPA must be authorized to submit production EDI transactions. Authorization is granted on a per-transaction basis. For example, a trading partner may be certified to submit 837P professional claims but not certified to submit 837I institutional claim files. Any TPA may submit test EDI transactions. The Usage Indicator, element 15 of the Interchange Control Header (ISA) of an X12 file, indicates if a file is test or production. Testing with the Payer Trading partners must submit three test files of a particular transaction type, with a minimum of fifteen transactions within each file, and have no failures or rejections to become certified for production. Users will be notified via e-mail and the Trading Partner Status page of the Health PAS website when testing for a particular transaction has been completed. The Trading Partner Status page is found by logging into your trading partner account on the Health PAS website (https://www.idmedicaid.com), hovering over the Account Management tab, and then clicking User Status. Detailed instructions for retrieving and interpreting HIPAA validation acknowledgments may be found on the Health PAS website under Companion Guides in the 5010 – Appendix A Vendor Specs document. Connectivity with the Payer/Communications Process Flows Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 4 of 22 4.1. Process Flows Below is the TPA Portal Services Process Flow (Retrieval of an 835 using the TPA Portal Services). Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 5 of 22 Below is the CAQH Web Services Process Flow (Generic Batch Retrieval Request of an 835). 4.2. Transmission Administrative Procedures X12 files (including an acknowledgment of an 835) can be uploaded via the Health PAS website File Exchange X12 Upload. 835 Healthcare Claim Payment Advice transaction files, acknowledgments, and responses to transactions submitted via the Health PAS website can be accessed by selecting Responses under the File Exchange menu. Trading Partners who have established a VAN connection and submitted X12 transactions via the VAN connection may retrieve acknowledgments and responses from their designated VAN Pickup locations. A VAN connection is a secure VPN connection through which X12 files are transferred via the FTP protocol. 4.3. Re-Transmission Procedure ISA13 – Interchange Control Number needs to be unique to each file and Trading Partner ID. 4.4. Communication Protocol Specifications The following communications protocols are available for receiving the ASC X12N 835 transaction Files. Batch Mode: HTTPS download via the Health PAS website FTP through a secure, dedicated VAN connection CAQH Web Service: Authorized trading partners can request 835 transactions through CAQH Web Services. Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 6 of 22 CAQH Phase III requires that a 999 be returned to the issuer of the 835 to acknowledge receipt and, if appropriate, report errors encountered with the 835 data1. The Gainwell Technologies CAQH Web Services have been enhanced to support this functionality. The CAQH Web Services support two types of transaction protocols: SOAP (Simple Object Access Protocol) and MIME (Multipurpose Internet Mail Extensions). Transactions can be sent through the following links: SOAP Transactions: https://www.idmedicaid.com/CAQH_SOAPService/SOAPService.svc MIME Transactions: https://www.idmedicaid.com/CAQH_MIMEService/MIMEService.svc When requesting an 835 using the CAQH Web Services: • The PayloadID needs to be set to the Check/EFT Payment ID for the desired 835 • The PayloadType needs to be specified as X12_835_Request_005010X221A1 • The ProcessingMode needs to be set to Batch • The requesting Trading Partner ID must match the Receiver ID of the 835 transaction requested When sending a 999 response using the CAQH Web Services: • Set the 999 AK102 to the value of the GS06 value for the 835 that the 999 is in response to • The PayloadType should be set to X12_999_SubmissionRequest_005010X231A1 • The ProcessingMode needs to be set to Batch The following Operations and Messages are supported: Operation Request Response GenericBatchRetrievalRequest GenericBatchRetrievalRequestMessage GenericBatchRetrievalResp onseMessage PayloadReceiptConfirmation PayloadReceiptConfirmationRequestMes sage PayloadReceiptConfirmatio nResponseMessage 4.5. Passwords Trading Partners create their passwords at the time of registration and are required to update them every 60 days per the Health PAS-Online requirements. The password must be at least seven (7) characters long, contain at least one (1) uppercase character, at least one (1) numeral, and at least one (1) special character (^#!). Contact Information This section contains detailed information concerning EDI Customer Service. 5.1. Gainwell Technologies EDI Helpdesk and EDI Technical Assistance 1 (866) 686-4272 option 2, or e-mail [email protected]. 5.2. Provider Service Number 1 (866) 686-4272 option 3, or e-mail [email protected]. 1 Note – CAQH has ruled that it is not mandatory for the receiver of an 835 to send a 999. If a 999 is sent, however, the system will accept it for processing. Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 7 of 22 5.3. Applicable Websites/E-mail The Idaho Medicaid Health PAS website contains companion guides, user guides, and other information needed to download the 835 Healthcare Claim Payment Advice transaction files. Website https://www.idmedicaid.com The e-mail addresses below can be used to contact Idaho Medicaid’s EDI Support, Provider Services, and Provider Enrollment departments. These groups can assist and answer questions relating to EDI file submissions, provider enrollment, and services. EDI Support [email protected] Provider Services [email protected] Provider Enrollment [email protected] Control Segments and Envelopes 6.1. Delimiters Idaho Medicaid does not require specific values for the delimiters used in electronic transactions. The suggested values are included in the specifications below. 6.2. ISA-IEA The following ISA/IEA fields are the sender and receiver specific information listed in the 835 transactions. For all other fields, please see the tables below. ISA06 – Interchange Sender ID will contain ID_MES_4_MMS_IG ISA08 – Interchange Receiver ID will contain the Gainwell Technologies assigned trading partner ID ISA13 – Sender generated Interchange Control Number. This number will match the number in IEA02 Please refer to the tables below for the ISA-IEA-specific information for the 835. 6.3. GS-GE The following GS/GE fields are the sender and receiver-specific information listed in the 835 transactions. For all other fields, please see the tables below. GS02 – Interchange Sender ID will contain ID_MES_4_MMS_IG GS03 – Interchange Receiver ID will contain the Gainwell Technologies assigned trading partner ID GS06 – Sender generated Group Control Number. Will match the number in GE02 Please refer to the tables below for the GS-GE-specific information for the 835 transactions. 6.4. ST-SE ST02 – Sender generated Transaction Set Control Number. Must match the number in SE02 Please refer to the tables below for the ST-SE-specific information for the 835 transactions. Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 8 of 22 Payer-Specific Business Rules and Limitations For Gainwell Technologies Healthcare-specific business rules and limitations associated with the ASC X12N 835 Healthcare Claim Payment Advice transaction, please refer to the tables under Section 10 below. Acknowledgments and/or Reports The 835 Healthcare Claim Payment Advice transaction files are generated weekly and advise/report on claims that are in their finalized status (paid, denied, reversed, etc.). Once generated, the 835 file(s) can be downloaded via the trading partner’s site. The following acknowledgments/reports related to the submission of EDI transactions by a trading partner are not sent out for 835 transactions. 8.1. Report Inventory (Not Sent for 835 Transactions) • TA1 – Interchange Acknowledgment. This acknowledgment is sent if requested by setting ISA14 to ‘1’ or if ISA14 is set to ‘0’ and there is an error that needs to be reported • 999 – Functional Acknowledgment. This acknowledgment file reports any errors found while checking compliance against TR3 specifications or acceptance of an EDI transaction that meets the TR3 specifications • 824 Application Advice report – This transaction is not mandated by HIPAA, but will be used to report the results of data content edits of transaction sets. It is designed to report rejections based on business rules, such as invalid diagnosis codes, invalid procedure codes, and invalid provider numbers. The 824 Application Advice report does not replace the 999 or TA1 transactions and will only be generated by Health PAS if there are errors within the transaction set • BRR – Business Rejection Report. Health PAS also produces a readable version of the 824 called the Business Rejection Report (BRR). This report helps to facilitate the immediate correction and re-bill of claims rejected during HIPAA validation Trading Partner Agreements A trading partner agreement is comprised of the completion of the trading partner registration activities and the approval to submit or receive specific transactions. Please refer to Section 2, sub-section Trading Partner Registration, for information on how to register as a trading partner and be authorized to send/receive EDI transactions. Transaction Specific Information Listed below in Figure 10-1 are the specific requirements for reading and processing an ASC X12N 835 Healthcare Claim Payment Advice transaction file returned by Gainwell Technologies. Please use these guidelines in conjunction with the official ASC X12N 835 TR3 document to read and process the downloaded 835 Healthcare Claim Payment Advice transaction files. Figure 10-1: 835 Healthcare Claim Payment Advice Page # Loop ID Reference Name Codes Length Notes / Comments C.3 HEAD ER ISA Interchange Control Header ISA 3 Element Separator 1 Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 9 of 22 Page # Loop ID Reference Name Codes Length Notes / Comments C.4 ISA01 Authorization Information Qualifier 00 2 Element Separator * 1 ISA02 Authorization Information Space Fill 10 Element Separator * 1 ISA03 Security Information Qualifier 00 2 Element Separator * 1 ISA04 Security Information [Not Used - Filled with Spaces] 10 Element Separator * 1 ISA05 Interchange ID Qualifier ZZ 2 Element Separator * 1 ISA06 Interchange Sender ID ID_MES_4_MMS_I G or ID_MMIS_4MOLINA or ID_MMIS_4_DXCM S 15 Element Separator * 1 C.5 ISA07 Interchange ID Qualifier ZZ - Mutually Defined] 2 Element Separator * 1 ISA08 Interchange Receiver ID Gainwell MS assigned Trading Partner ID 15 Gainwell MS assigned at registration C.5 Element Separator * 1 ISA09 Interchange Date YYMMDD 6 Element Separator * 1 ISA10 Interchange Time HHMM 4 Element Separator * 1 ISA11 Repetition Separator ^ 1 Element Separator * 1 ISA12 Interchange Version Number 00501 5 Element Separator * 1 ISA13 Interchange Control Number Assigned by Sender 9 (must be identical to interchange trailer IEA02) Element Separator * 1 C.6 ISA14 Acknowledgment Requested 0 - No Ack. Requested 1 Element Separator * 1 ISA15 Usage Indicator P 1 Element Separator * 1 ISA16 Component Element Separator : 1 Segment End ~ 1 C.7 GS Functional Group Header GS 2 Element Separator * 1 GS01 Functional Identifier Code HP 2 C.7 Element Separator * 1 GS02 Application Sender's Code Must be identical to the value in the ISA06 6 Element Separator * 1 GS03 Application Receiver's Code Gainwell MS assigned Trading Partner ID 2/15 This is assigned during trading partner registration Element Separator * 1 C.8 GS04 Date CCYYMMDD 8 Element Separator * 1 Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 10 of 22 Page # Loop ID Reference Name Codes Length Notes / Comments GS05 Time HHMM 4/8 Time based on a 24- hour clock Element Separator * 1 GS06 Group Control Number (Assigned by Sender) Must be identical to the value in the GS02 1/9 Element Separator * 1 GS07 Responsible Agency Code X 1/2 Element Separator * 1 GS08 Version / Release Code	CAQH 5010 835 Companion Guide (1).pdf
Agreements A trading partner agreement is comprised of the completion of the trading partner registration activities and the approval to submit or receive specific transactions. Please refer to Section 2, sub-section Trading Partner Registration, for information on how to register as a trading partner and be authorized to send/receive EDI transactions. Transaction Specific Information Listed below in Figure 10-1 are the specific requirements for reading and processing an ASC X12N 835 Healthcare Claim Payment Advice transaction file returned by Gainwell Technologies. Please use these guidelines in conjunction with the official ASC X12N 835 TR3 document to read and process the downloaded 835 Healthcare Claim Payment Advice transaction files. Figure 10-1: 835 Healthcare Claim Payment Advice Page # Loop ID Reference Name Codes Length Notes / Comments C.3 HEAD ER ISA Interchange Control Header ISA 3 Element Separator * 1 Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 9 of 22 Page # Loop ID Reference Name Codes Length Notes / Comments C.4 ISA01 Authorization Information Qualifier 00 2 Element Separator * 1 ISA02 Authorization Information Space Fill 10 Element Separator * 1 ISA03 Security Information Qualifier 00 2 Element Separator * 1 ISA04 Security Information [Not Used - Filled with Spaces] 10 Element Separator * 1 ISA05 Interchange ID Qualifier ZZ 2 Element Separator * 1 ISA06 Interchange Sender ID ID_MES_4_MMS_I G or ID_MMIS_4MOLINA or ID_MMIS_4_DXCM S 15 Element Separator * 1 C.5 ISA07 Interchange ID Qualifier ZZ - Mutually Defined] 2 Element Separator * 1 ISA08 Interchange Receiver ID Gainwell MS assigned Trading Partner ID 15 Gainwell MS assigned at registration C.5 Element Separator * 1 ISA09 Interchange Date YYMMDD 6 Element Separator * 1 ISA10 Interchange Time HHMM 4 Element Separator * 1 ISA11 Repetition Separator ^ 1 Element Separator * 1 ISA12 Interchange Version Number 00501 5 Element Separator * 1 ISA13 Interchange Control Number Assigned by Sender 9 (must be identical to interchange trailer IEA02) Element Separator * 1 C.6 ISA14 Acknowledgment Requested 0 - No Ack. Requested 1 Element Separator * 1 ISA15 Usage Indicator P 1 Element Separator * 1 ISA16 Component Element Separator : 1 Segment End ~ 1 C.7 GS Functional Group Header GS 2 Element Separator * 1 GS01 Functional Identifier Code HP 2 C.7 Element Separator * 1 GS02 Application Sender's Code Must be identical to the value in the ISA06 6 Element Separator * 1 GS03 Application Receiver's Code Gainwell MS assigned Trading Partner ID 2/15 This is assigned during trading partner registration Element Separator * 1 C.8 GS04 Date CCYYMMDD 8 Element Separator * 1 Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 10 of 22 Page # Loop ID Reference Name Codes Length Notes / Comments GS05 Time HHMM 4/8 Time based on a 24- hour clock Element Separator * 1 GS06 Group Control Number (Assigned by Sender) Must be identical to the value in the GS02 1/9 Element Separator * 1 GS07 Responsible Agency Code X 1/2 Element Separator * 1 GS08 Version / Release Code 005010X221A1 1/12 Segment End ~ 1 68 ST Transaction Set Header ST 2 Element Separator * 1 ST01 Transaction Set Identification Code 835 3 Element Separator * 1 ST02 Transaction Set Control Number Sequential number assigned by sender ST02 and SE02 must be identical 4/9 Segment End ~ 1 69 HEAD ER BPR Financial Information BPR 3 70 BPR01 Transaction Handling Code I – remittance information only 1/2 Element Separator * 1 71 BPR02 Monetary Amount 1/18 Payment amount Element Separator * 1 BPR03 Credit/Debit Flag code C – Credit - payment to the receiver’s account 1 Element Separator * 1 72 BPR04 Payment Method Code CHK – Check BOP – Financial Institution Option 3 Payment Format Code * 1/10 Element Separator * 1 73 BPR06 (DFI)ID Number Qualifier 01 when BPR04 = BOP 2 Element Separator * 1 BPR07 (DFI) Identification Number 3/12 Required when BPR04 = BOP Element Separator * 1 74 BPR08 Account Number Qualifier DA - Demand Deposit when BPR04 = BOP 1/3 Element Separator * 1 BPR09 Account Number Required when BPR04 = BOP Element Separator * 1 BPR10 Originating Company Identifier 10 Required when BPR04 = BOP Element Separator * 1 Element Separator * 1 75 BPR12 (DFI) ID Number Qualifier 01 - ABATransit Routing Number Including Check Digits when BPR04 = BOP 2 Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 11 of 22 Page # Loop ID Reference Name Codes Length Notes / Comments Element Separator * 1 BPR13 (DFI) Identification Number 3/12 Bank Number Element Separator * 1 76 BPR14 Account Number Qualifier 1/3 Account Type Element Separator * 1 BPR15 Account Number 1/35 Bank Account Number Element Separator * 1 BPR16 Date CCYYMMDD 8 EFT or Check Issue Date Segment End ~ 1 77 HEAD ER TRN Reassociation Trace Number TRN 3 Element Separator * 1 TRN01 Trace Type Code 1 – Current Transaction Trace Number 1/2 Element Separator * 1 TRN02 Reference Identification 1/50 Check or EFT Trace Number Element Separator * 1 * TRN03 Originating Company Identifier 10 Payer Identifier Segment End ~ 1 85 HEAD ER DTM Production Date DTM 3 Element Separator * 1 DTM01 Date/Time Qualifier 405 – Production 3 Element Separator * 1 86 DTM02 Date CCYYMMDD 8 Production Date Segment End ~ 1 87 1000A N1 Payer Identification N1 2 Element Separator * 1 N101 Entity Identifier Code PR – Payer 2/3 Element Separator * 1 N102 Name 1/60 Payer Name Segment End ~ 1 89 1000A N3 Payer Address N3 2 Element Separator * 1 N301 Address Information Payer Address 1/55 Payer Address Segment Terminator ~ 1 90 1000A N4 Payer City, State, ZIP Code N4 2 Element Separator * 1 N401 City Name 2/30 City Element Separator * 1 91 N402 State or Province Code 2 State - Required if address is in the United States Element Separator * 1 N403 Postal Code 3/15 Zip Code - Required if address is in the United States Segment Terminator ~ 1 94 1000A PER Payer Business Contact Information PER 3 Element Separator * 1 95 PER01 Contact Function Code CX – Payers Claim Office 2 Element Separator * 1 PER02 Name 1/60 Contact Name Element Separator * 1 Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 12 of 22 Page # Loop ID Reference Name Codes Length Notes / Comments PER03 Communication Number Qualifier TE – Telephone 2 Element Separator * 1 PER04 Communication Number AAABBBCCCC 1/256 Contact Number Segment End ~ 1 97 1000A PER Payer Technical Contact Information PER 3 Element Separator * 1 PER01 Contact Function Code BL – Technical Department 2 Element Separator * 1 98 PER02 Name 1/60 Contact Name Element Separator * 1 PER03 Communication Number Qualifier TE – Telephone 2 Element Separator * 1 PER04 Communication Number AAABBBCCCC 1/256 Contact Number Segment Terminator ~ 1 102 1000B N1 Payee Identification N1 2 Element Separator * 1 N101 Entity Identifier Code PE – Payee 2/3 Element Separator * 1 N102 Name 1/60 Provider Name Element Separator * 1 103 N103 Identification Code Qualifier FI – Federal Taxpayer’s Identification Number XX – Health Care Financing Administration National Provider ID 1/2 Element Separator * 1 N104 Identification Code 2/80 Identification Code - NPI or Tax ID Segment Terminator ~ 1 104 1000B N3 Payee Address N3 2 Element Separator * 1 N301 Address Information 1/55 Payee Address Line 1 – Street, PO Element Separator * 1 N302 Address Information 1/55 Address Line 2 - Suite Segment Terminator ~ 1 105 1000B N4 Payee City, State, ZIP Code N4 2 Element Separator * 1 N401 City Name 2/30 City Element Separator * 1 106 N402 State or Province Code 2 Required if address is in the United States Element Separator * 1 N403 Postal Code 3/15 Required if address is in the United States Segment Terminator ~ 1 107 1000B REF Payee Additional identification REF 3 Reference Identification Element Separator * 1 REF01 Reference Identification Qualifier TJ – SSN FEIN Qualifier, If N103 = XX 2/3 Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 13 of 22 Page # Loop ID Reference Name Codes Length Notes / Comments PQ – Payee Identification – Molina Element Separator * 1 108 REF02 Reference Identification 1/50 SSN FEIN (Tax ID) if REF01(1) = TJ Segment Terminator ~ 1 111 2000 LX Header Number LX 2 Element Separator * 1 LX01 Assigned Number 1/6 Sequential Number Segment Terminator ~ 1 123 2100 CLP Claim Payment Information CLP 3 Claim Level Data CLP01 is from CLM01 of the original claim (generated by the provider) Element Separator * 1 CLP01 Claim Submitter’s Identifier 1/38 Provider Claim ID (also known as the Patient Control Number) Element Separator * 1 124 CLP02 Claim Status Code 1 – Paid Primary 2 – Paid Secondary 3 – Paid Tertiary 4 – Denied 22 – Reversal 1/2 Element Separator * 1 125 CLP03 Monetary Amount 1/18 Billed Amount – The billed amount for each claim Element Separator * 1 125 CLP04 Monetary Amount 1/18 Paid Amount – The dollar amount included in the payment for the claim Element Separator * 1 CLP05 Monetary Amount 1/18 Co-Pay Amount Element Separator * 1 126 CLP06 Claim Filing Indicator Code MC - Medicaid 1/2 Code Identifying the type of claim Element Separator * 1 127 CLP07 Reference Identification 1/50 Claim Internal Control Number (ICN) Element Separator * 1 CLP08 Facility Code Value 1/2 Place of Service. Facility Service Code and Claim Frequency Type Code come from CLM05-1 and -2 of 837 Claim Element Separator * 1 CLP09 Claim Frequency Type Code 1 Claim Frequency Type Code. Facility Service Code and Claim Frequency Type Code come from CLM05-1 and -2 of 837 Claim Segment Terminator ~ 1 Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 14 of 22 Page # Loop ID Reference Name Codes Length Notes / Comments 129 2100 CAS Claims Adjustment CAS 3 Claim Adjustment (see note at end of CAS segment) Element Separator * 1 131 CAS01 Claim Adjustment Group Code CO – Contractual Obligations OA – Other Adjustments PI – Payer Initiated Reduction PR – Patient Responsibility 1/2 Element Separator * 1 CAS02 Claim Adjustment Reason Code 1/5 First claim adjustment reason code Element Separator * 1 132 CAS03 Monetary Amount 1/18 First claim adjustment amount Element Separator * 1 Element Separator * 1 CAS05 Claim Adjustment Reason Code 1/5 Second claim adjustment reason code Element Separator * 1 133 CAS06 Monetary Amount 1/18 Second claim adjustment amount Element Separator * 1 Element Separator * 1 CAS08 Claim Adjustment Reason Code 1/5 Third claim adjustment reason code Element Separator * 1 CAS09 Monetary Amount 1/18 Third claim adjustment amount Element Separator * 1 134 Element Separator * 1 CAS11 Claim Adjustment Reason Code 1/5 Fourth claim adjustment reason code Element Separator * 1 CAS12 Monetary Amount 1/18 Fourth claim adjustment amount Element Separator * 1 Element Separator * 1 135 CAS14 Claim Adjustment Reason Code 1/5 Fifth claim adjustment reason code Element Separator * 1 CAS15 Monetary Amount 1/18 Fifth claim adjustment amount Element Separator * 1 Element Separator * 1 CAS17 Claim Adjustment Reason Code 1/5 Sixth claim adjustment reason code Element Separator * 1 136 CAS18 Monetary Amount 1/18 Sixth claim adjustment amount Segment Terminator ~ 1 Note: Additional CAS segments (up to 99 Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 15 of 22 Page # Loop ID Reference Name Codes Length Notes / Comments total) will be mapped if there are more than six (6) EOB codes passed. 137 2100 NM1 Patient Name NM1 3 Individual or Organizational Name Element Separator * 1 NM101 Entity Identifier Code QC – Patient Name 2 Element Separator * 1 138 NM102 Entity Type Qualifier 1 – Person 1 Element Separator * 1 NM103 Name, Last or Organization Name 1/60 Client Last Name Required for all claims that are not retail pharmacy claims. Required for retail pharmacy claims when the information is known. Element Separator * 1 NM104 Name, First 1/35 Client First Name Required when	CAQH 5010 835 Companion Guide (1).pdf
The dollar amount included in the payment for the claim Element Separator * 1 CLP05 Monetary Amount 1/18 Co-Pay Amount Element Separator * 1 126 CLP06 Claim Filing Indicator Code MC - Medicaid 1/2 Code Identifying the type of claim Element Separator * 1 127 CLP07 Reference Identification 1/50 Claim Internal Control Number (ICN) Element Separator * 1 CLP08 Facility Code Value 1/2 Place of Service. Facility Service Code and Claim Frequency Type Code come from CLM05-1 and -2 of 837 Claim Element Separator * 1 CLP09 Claim Frequency Type Code 1 Claim Frequency Type Code. Facility Service Code and Claim Frequency Type Code come from CLM05-1 and -2 of 837 Claim Segment Terminator ~ 1 Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 14 of 22 Page # Loop ID Reference Name Codes Length Notes / Comments 129 2100 CAS Claims Adjustment CAS 3 Claim Adjustment (see note at end of CAS segment) Element Separator * 1 131 CAS01 Claim Adjustment Group Code CO – Contractual Obligations OA – Other Adjustments PI – Payer Initiated Reduction PR – Patient Responsibility 1/2 Element Separator * 1 CAS02 Claim Adjustment Reason Code 1/5 First claim adjustment reason code Element Separator * 1 132 CAS03 Monetary Amount 1/18 First claim adjustment amount Element Separator * 1 Element Separator * 1 CAS05 Claim Adjustment Reason Code 1/5 Second claim adjustment reason code Element Separator * 1 133 CAS06 Monetary Amount 1/18 Second claim adjustment amount Element Separator * 1 Element Separator * 1 CAS08 Claim Adjustment Reason Code 1/5 Third claim adjustment reason code Element Separator * 1 CAS09 Monetary Amount 1/18 Third claim adjustment amount Element Separator * 1 134 Element Separator * 1 CAS11 Claim Adjustment Reason Code 1/5 Fourth claim adjustment reason code Element Separator * 1 CAS12 Monetary Amount 1/18 Fourth claim adjustment amount Element Separator * 1 Element Separator * 1 135 CAS14 Claim Adjustment Reason Code 1/5 Fifth claim adjustment reason code Element Separator * 1 CAS15 Monetary Amount 1/18 Fifth claim adjustment amount Element Separator * 1 Element Separator * 1 CAS17 Claim Adjustment Reason Code 1/5 Sixth claim adjustment reason code Element Separator * 1 136 CAS18 Monetary Amount 1/18 Sixth claim adjustment amount Segment Terminator ~ 1 Note: Additional CAS segments (up to 99 Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 15 of 22 Page # Loop ID Reference Name Codes Length Notes / Comments total) will be mapped if there are more than six (6) EOB codes passed. 137 2100 NM1 Patient Name NM1 3 Individual or Organizational Name Element Separator * 1 NM101 Entity Identifier Code QC – Patient Name 2 Element Separator * 1 138 NM102 Entity Type Qualifier 1 – Person 1 Element Separator * 1 NM103 Name, Last or Organization Name 1/60 Client Last Name Required for all claims that are not retail pharmacy claims. Required for retail pharmacy claims when the information is known. Element Separator * 1 NM104 Name, First 1/35 Client First Name Required when the patient has a first name, and it is known. Element Separator * 1 NM105 Name, Middle 1/25 Client Middle Name Element Separator * 1 Element Separator * 1 NM107 Name, Suffix 1/10 Client Name Suffix Element Separator * 1 139 NM108 Identification Code Qualifier MI – Member Identification Number 1/2 Element Separator * 1 NM109 Identification Code 2/80 Client Medicaid ID Number Segment Terminator ~ 1 146 2100 NM1 Service Provider Name NM1 3 Element Separator * 1 147 NM101 Entity Identifier Code 82 – Rendering Provider 2/3 Element Separator * 1 NM102 Entity Type Qualifier 1 – Person 2 – Non-Person 1 Element Separator * 1 NM103 Name, Last or Organization Name 1/60 Rendering Provider Last Name Element Separator * 1 NM104 Name, First 1/35 Rendering Provider First Name Element Separator * 1 148 Element Separator * 1 Element Separator * 1 Element Separator * 1 NM108 Identification code Qualifier XX – National Provider ID MC – Medicaid Provider Number 1/2 Element Separator * 1 Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 16 of 22 Page # Loop ID Reference Name Codes Length Notes / Comments 149 NM109 Identification Code 2/80 NPI or Provider ID Segment Terminator ~ 1 Note: For TPL Claims: Information for up to three (3) Insurance Companies may be transmitted in N1 segments. If the insurance company name is not available, there will be no NM1 segments for the company. If both the company name and policyholder numbers are not available, neither NM1 segment will be mapped. 153 2100 NM1 Corrected Priority Payer Name NM1 3 Element Separator * 1 NM101 Entity Identifier Code PR – Payer 2/3 Element Separator * 1 154 NM102 Entity Type Qualifier 2 – Non-Person Entity 1 Element Separator * 1 NM103 Name, Last or Organization Name 1/60 Corrected Priority Payer Name Element Separator * 1 Element Separator * 1 Element Separator * 1 Element Separator * 1 Element Separator * 1 NM108 Identification code Qualifier PI – Payer Identification 1/2 NM109 Identification Code 2/80 Payer Identification Number Segment Terminator ~ 1 173 2100 DTM Statement From or To Date DTM 3 Claim Date Element Separator * 1 174 DTM01 Date/Time Qualifier 232 – “From” Date of Service 233 – “To” Date of Service 3 Element Separator * 1 DTM02 Date CCYYMMDD 8/8 “From” Date of Service where DTM01 = 232 “To” Date of Service where DTM01 = 233 Segment Terminator ~ 1 175 2100 DTM Coverage Expiration Date DTM 3 Element Separator * 1 DTM01 Date/Time Qualifier 036 – Expiration 3 Element Separator * 1 DTM02 Date CCYYMMDD 8 Segment Terminator ~ 1 177 2100 DTM Claim Receive Date DTM 3 Element Separator * 1 DTM01 Date/Time Qualifier 050 - Received 3 Element Separator * 1 Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 17 of 22 Page # Loop ID Reference Name Codes Length Notes / Comments DTM02 Date CCYYMMDD 8 Segment Terminator ~ 1 184 2100 QTY Claim Supplemental Information Quantity QTY 3 Quantity – Gainwell MS uses this segment; ID does not Element Separator * 1 QTY01 Quantity Qualifier 2 Element Separator * 1 185 QTY02 Quantity 1/15 Segment Terminator ~ 1 186 2110 SVC Service Payment Information SVC 3 187 SVC01-1 Product/Service ID Qualifier AD – American Dental Association Codes HC – HCFA HCPCS Codes N4 – National Drug code 5-4-2 format 2 Component Separator : 1 188 SVC01-2 Product/Service ID 1/48 Product/Service Drug code Component Separator : 1 SVC01-3 Procedure Modifier 2 Modifier-1 Component Separator : 1 189 SVC01-4 Procedure Modifier 2 Modifier-2 Component Separator : 1 SVC01-5 Procedure Modifier 2 Modifier-3 Component Separator : 1 SVC01-6 Procedure Modifier 2 Modifier-4 Element Separator * 1 SVC02 Monetary Amount 1/18 Total Charges Billed Element Separator * 1 190 SVC03 Monetary Amount 1/18 Provider Payment Amount Element Separator * 1 SVC04 Product/Service ID 1/48 Revenue Code Element Separator * 1 SVC05 Quantity 1/15 Paid Quantity Element Separator * 1 Element Separator * 1 193 SVC07 Quantity 1/15 Quantity Billed - if different from SVC05 Segment Terminator ~ 1 194 2110 DTM Service Date DTM 3 2110 Element Separator * 1 195 DTM01 Date/Time Qualifier 150 – Service Period Start 151 – Service Period End 472 – Service (for single-day service) 3 Element Separator * 1 DTM02 Date CCYYMMDD 8 Service Date Segment Terminator ~ 1 196 2110 CAS Service Adjustment CAS 3 see note #3 below Element Separator * 1 198 CAS01 Claim Adjustment Group Code CO – Contractual Obligations OA – Other Adjustments 1/2 Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 18 of 22 Page # Loop ID Reference Name Codes Length Notes / Comments PR – Patient Responsibility Element Separator * 1 CAS02 Claim Adjustment Reason Code 1/5 First claim adjustment reason code Element Separator * 1 199 CAS03 Monetary Amount 1/18 First claim adjustment amount Element Separator * 1 Element Separator * 1 CAS05 Claim Adjustment Reason Code 1/5 Second claim adjustment reason code Element Separator * 1 CAS06 Monetary Amount 1/18 Second claim adjustment amount Element Separator * 1 200 Element Separator * 1 CAS08 Claim Adjustment Reason Code 1/5 Third claim adjustment reason code Element Separator * 1 CAS09 Monetary Amount 1/18 Third claim adjustment amount Element Separator * 1 Element Separator * 1 201 CAS11 Claim Adjustment Reason Code 1/5 Fourth claim adjustment reason code Element Separator * 1 CAS12 Monetary Amount 1/18 Fourth claim adjustment amount Element Separator * 1 Element Separator * 1 202 CAS14 Claim Adjustment Reason Code 1/5 Fifth claim adjustment reason code Element Separator * 1 CAS15 Monetary Amount 1/18 Fifth claim adjustment amount Element Separator * 1 Element Separator * 1 203 CAS17 Claim Adjustment Reason Code 1/5 Sixth claim adjustment reason code Element Separator * 1 CAS18 Monetary Amount 1/18 Sixth claim adjustment amount Segment Terminator ~ 1 Note: At a minimum, the Claim Detail CAS segment will contain the Claim Adjustment Group Code (CAS01), Claim Adjustment Code 1 (CAS02), and Adjustment Amount (CAS03). No other fields will be transmitted if there is no data. Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 19 of 22 Page # Loop ID Reference Name Codes Length Notes / Comments Note: A second CAS segment for the Claim Detail will be mapped if more than six (6) detail EOB codes are passed. 204 2110 REF Service Identification REF 3 Element Separator * 1 REF01 Reference Identification Qualifier BB – Authorization Number 2/3 Element Separator * 1 205 REF02 Reference Identification 1/50 Trace Service Line Segment Terminator ~ 1 206 2110 REF Line Item Control Number REF 3 Element Separator * 1 REF01 Reference Identification Qualifier 6R – Provider Control Number 2/3 Element Separator * 1 REF02 Reference Identification 1/50 Line Item Control Number Segment Terminator ~ 1 Note: Second REF segment for Rendering or Attending Provider Information exists and is populated with Medicaid Provider number only when the REF01 value in the previous REF segment is ‘BB’ and its corresponding REF02 value is equal to a National Provider ID and when a Rendering or Attending Provider Number exists. 209 2110 REF Healthcare Policy Identification REF 3 Element Separator * 1 210 REF01 Reference Identification Qualifier 0K – Policy Form Identifying Number 2/3 Element Separator * 1 REF02 Reference Identification 1/50 Healthcare Policy Identification Segment Terminator ~ 1 211 2110 AMT Service Supplemental Amount AMT 3 Element Separator * 1 AMT01 Amount Qualifier Code B6 – Allowed Actual 1/3 Element Separator * 1 212 AMT02 Monetary Amount 1/18 Amount Allowed Segment Terminator ~ 1 215 2110 LQ Industry Code – Health Care Remark Codes LQ 2 Element Separator * 1 LQ01 Code List Qualifier Code HE – Allowed Actual 1/3 Element Separator * 1 216 LQ02 Industry Code 1/30 Remark Code Segment Terminator Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 20 of 22 Page # Loop ID Reference Name Codes Length Notes / Comments 217 Summ ary PLB Provider Adjustment PLB 3 Transaction Set Trailer Element Separator * 1 218 PLB01 Reference Identification 1/50 Provider Number (If the Provider has an NPI, the NPI is used) Summ ary Element Separator * 1 PLB02 Date CCYYMMDD 8 Last Day of Current Year Element Separator * 1 219 PLB03-1 Adjustment Reason Code 2 Reason Code 1 Component Separator : 1 222 PLB03-2 Reference Identification 1/50 Reference Number 1 – May be a Cash Control Number (CCN) or Internal Control Number (ICN) Element Separator * 1 223 PLB04 Monetary Amount 1/18 Adjustment Amount 1 – This field may also be “NEGATIVE PAYMENT” due to insufficient positive cash flow Element Separator * 1 PLB05-1 Adjustment Reason Code 2 Reason Code 2 Component Separator : 1 PLB05-2 Reference Identification 1/50 Reference number 2 – See Reference Number 1 Element Separator * 1 224 PLB06 Monetary Amount 1/18 Adjustment Amount 2 – See Adjustment Amount 1 Element Separator * 1 PLB07-1 Adjustment Reason Code 2 Reason Code 3 Component Separator : 1 PLB07-2 Reference Identification 1/50 Reference number 3 – See Reference Number 1 Element Separator * 1 PLB08 Monetary Amount 1/18 Adjustment Amount 3	CAQH 5010 835 Companion Guide (1).pdf
MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 19 of 22 Page # Loop ID Reference Name Codes Length Notes / Comments Note: A second CAS segment for the Claim Detail will be mapped if more than six (6) detail EOB codes are passed. 204 2110 REF Service Identification REF 3 Element Separator * 1 REF01 Reference Identification Qualifier BB – Authorization Number 2/3 Element Separator * 1 205 REF02 Reference Identification 1/50 Trace Service Line Segment Terminator ~ 1 206 2110 REF Line Item Control Number REF 3 Element Separator * 1 REF01 Reference Identification Qualifier 6R – Provider Control Number 2/3 Element Separator * 1 REF02 Reference Identification 1/50 Line Item Control Number Segment Terminator ~ 1 Note: Second REF segment for Rendering or Attending Provider Information exists and is populated with Medicaid Provider number only when the REF01 value in the previous REF segment is ‘BB’ and its corresponding REF02 value is equal to a National Provider ID and when a Rendering or Attending Provider Number exists. 209 2110 REF Healthcare Policy Identification REF 3 Element Separator * 1 210 REF01 Reference Identification Qualifier 0K – Policy Form Identifying Number 2/3 Element Separator * 1 REF02 Reference Identification 1/50 Healthcare Policy Identification Segment Terminator ~ 1 211 2110 AMT Service Supplemental Amount AMT 3 Element Separator * 1 AMT01 Amount Qualifier Code B6 – Allowed Actual 1/3 Element Separator * 1 212 AMT02 Monetary Amount 1/18 Amount Allowed Segment Terminator ~ 1 215 2110 LQ Industry Code – Health Care Remark Codes LQ 2 Element Separator * 1 LQ01 Code List Qualifier Code HE – Allowed Actual 1/3 Element Separator * 1 216 LQ02 Industry Code 1/30 Remark Code Segment Terminator Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 20 of 22 Page # Loop ID Reference Name Codes Length Notes / Comments 217 Summ ary PLB Provider Adjustment PLB 3 Transaction Set Trailer Element Separator * 1 218 PLB01 Reference Identification 1/50 Provider Number (If the Provider has an NPI, the NPI is used) Summ ary Element Separator * 1 PLB02 Date CCYYMMDD 8 Last Day of Current Year Element Separator * 1 219 PLB03-1 Adjustment Reason Code 2 Reason Code 1 Component Separator : 1 222 PLB03-2 Reference Identification 1/50 Reference Number 1 – May be a Cash Control Number (CCN) or Internal Control Number (ICN) Element Separator * 1 223 PLB04 Monetary Amount 1/18 Adjustment Amount 1 – This field may also be “NEGATIVE PAYMENT” due to insufficient positive cash flow Element Separator * 1 PLB05-1 Adjustment Reason Code 2 Reason Code 2 Component Separator : 1 PLB05-2 Reference Identification 1/50 Reference number 2 – See Reference Number 1 Element Separator * 1 224 PLB06 Monetary Amount 1/18 Adjustment Amount 2 – See Adjustment Amount 1 Element Separator * 1 PLB07-1 Adjustment Reason Code 2 Reason Code 3 Component Separator : 1 PLB07-2 Reference Identification 1/50 Reference number 3 – See Reference Number 1 Element Separator * 1 PLB08 Monetary Amount 1/18 Adjustment Amount 3 – See Adjustment Amount 1 Element Separator * 1 225 PLB09-1 Adjustment Reason Code 2 Reason Code 4 Component Separator : 1 PLB09-2 Reference Identification 1/50 Reference number 4 – See Reference Number 1 Element Separator * 1 PLB10 Monetary Amount 1/18 Adjustment Amount 4 – See Adjustment Amount 1 Element Separator * 1 PLB11-1 Adjustment Reason Code 2 Reason Code 5 Component Separator : 1 226 PLB11-2 Reference Identification 1/50 Reference number 5 – See Reference Number 1 Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 21 of 22 Page # Loop ID Reference Name Codes Length Notes / Comments Element Separator * 1 PLB12 Monetary Amount 1/18 Adjustment Amount 5 – See Adjustment Amount 1 Summ ary Element Separator * 1 PLB13-1 Adjustment Reason Code 2 Reason Code 6 Component Separator : 1 PLB13-2 Reference Identification 1/50 Reference number 6 – See Reference Number 1 Element Separator * 1 227 PLB14 Monetary Amount 1/18 Adjustment Amount 6 – See Adjustment Amount 1 Segment Terminator ~ 1 228 TRAIL ER SE Transaction Set Trailer SE 2/3 Element Separator * 1 SE01 Number of Included Segments 1/10 Total number of ST through SE segments Element Separator * 1 SE02 Transaction Set Control Number 4/9 Assigned by Sender Must be identical to the value in ST02 Segment Terminator ~ 1 C.9 GE Functional Group Trailer GE 2 Element Separator * 1 GE01 Number of Transaction Sets Included 1 1/6 Element Separator * 1 GE02 Group Control Number 1/9 Assigned by Sender Must be identical to the value in GS06 Segment Terminator ~ 1 C.10 IEA Interchange Control Trailer IEA 3 Element Separator * 1 IEA01 Number of Included Functional Groups 1 1/5 Element Separator * 1 IEA02 Interchange Control Number 9 Assigned by Sender - Pad Left with Zeros Must be identical to value ISA13 Segment Terminator ~ 1 Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 22 of 22 Appendices Appendix A. Implementation Checklist The Trading Partner Account (TPA) User Guide contains information on how to select the correct trading partner entity type and answers some preliminary questions concerning trading partner registration. This guide can be found on the User Guides link under Reference Material on www.idmedicaid.com.	CAQH 5010 835 Companion Guide (1).pdf
Centers for Medicare & Medicaid Services (CMS) Standard Companion Guide Health Care Claim Institutional (837I) Based on ASC X12N TR3, Version 005010X223A2 Companion Guide Version Number: 8.0, June 2023 CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. ii Disclosure Statement The Centers for Medicare & Medicaid Services (CMS) is committed to maintaining the integrity and security of health care data in accordance with applicable laws and regulations. Disclosure of Medicare claims is restricted under the provisions of the Privacy Act of 1974 and Health Insurance Portability and Accountability Act of 1996. This Companion Guide is to be used for conducting Medicare business only. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. iii Preface This Companion Guide (CG) to the ASC X12N Technical Report Type 3 (TR3) Version 005010 and associated errata adopted under Health Insurance Portability and Accountability Act of 1996 (HIPAA) clarifies and specifies the data content when exchanging transactions electronically with Medicare. Transmissions based on this CG, used in tandem with the TR3, are compliant with both ASC X12N syntax and those guides. This CG is intended to convey information that is within the framework of the TR3 adopted for use under HIPAA. This CG is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the TR3. This CG contains instructions for electronic communications with the publishing entity, as well as supplemental information, for creating transactions while ensuring compliance with the associated ASC X12N TR3s and the Council for Affordable Quality Healthcare – Committee on Operating Rules for Information Exchange (CAQH CORE) companion guide operating rules. In addition, this CG contains the information needed by Trading Partners to send and receive electronic data with the publishing entity, who is acting on behalf of CMS, including detailed instructions for submission of specific electronic transactions. The instructional content is limited by ASC X12N’s copyrights and Fair Use statement. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. iv Table of Contents Disclosure Statement ...............................................................................................................................................ii Preface .................................................................................................................................................................... iii 1 Introduction .................................................................................................................................................... 1 1.1 Scope ......................................................................................................................................................... 1 1.2 Overview .................................................................................................................................................... 2 1.3 References ................................................................................................................................................. 2 1.4 Additional Information .............................................................................................................................. 3 2 Getting Started ................................................................................................................................................ 3 2.1 Working Together ...................................................................................................................................... 3 2.2 Trading Partner Registration ..................................................................................................................... 3 2.3 Trading Partner Certification and Testing Process .................................................................................... 5 3 Testing and Certification Requirements ......................................................................................................... 6 3.1 Testing Requirements ................................................................................................................................ 6 3.2 Certification Requirements ....................................................................................................................... 7 4 Connectivity / Communications ...................................................................................................................... 7 4.1 Process Flows............................................................................................................................................. 7 4.2 Transmission .............................................................................................................................................. 8 4.2.1 Re-transmission Procedures ............................................................................................................. 8 4.3 Communication Protocol Specifications ................................................................................................... 9 4.4 Security Protocols and Passwords ............................................................................................................. 9 5 Contact Information ........................................................................................................................................ 9 5.1 EDI Customer Service ................................................................................................................................ 9 5.2 EDI Technical Assistance .......................................................................................................................... 10 5.3 Trading Partner Service Number ............................................................................................................. 10 5.4 Applicable Websites / Email .................................................................................................................... 11 6 Control Segments / Envelopes ...................................................................................................................... 11 6.1 ISA-IEA ..................................................................................................................................................... 12 Delimiters – Inbound Transactions ......................................................................................................... 12 Delimiters – Outbound Transactions ...................................................................................................... 12 Inbound Data Element Detail and Explanation ....................................................................................... 13 6.2 GS-GE ....................................................................................................................................................... 13 6.3 ST-SE ........................................................................................................................................................ 13 7 Specific Business Rules .................................................................................................................................. 13 7.1 General Notes .......................................................................................................................................... 13 8 Acknowledgments and Reports .................................................................................................................... 14 8.1 Report Inventory ..................................................................................................................................... 15 9 Trading Partner Agreement .......................................................................................................................... 15 CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. v 10 Transaction-Specific Information .................................................................................................................. 15 10.1 Header ................................................................................................................................................... 15 10.1.1 Header and Information Source ................................................................................................... 15 10.1.2 Loop 1000A Submitter Name ....................................................................................................... 16 10.1.3 Loop 1000B Receiver Name ......................................................................................................... 17 10.2 Billing Provider ....................................................................................................................................... 17 10.2.1 Loop 2010AA Billing Provider ....................................................................................................... 17 10.3 Subscriber Detail.................................................................................................................................... 17 10.3.1 Loop 2000B Subscriber Hierarchical Level ................................................................................... 17 10.3.2 Loop 2010BA Subscriber Name .................................................................................................... 18 10.3.3 Loop 2010BB Payer Name ............................................................................................................ 19 10.4 Patient Detail ......................................................................................................................................... 20 10.4.1 Loop 2300 Claim Information ....................................................................................................... 20 10.4.2 Loop 2310A Attending Provider Name ........................................................................................ 21 10.4.3 Loop 2310B Operating Physician Name ....................................................................................... 21 10.4.4 Loop 2310C Other Operating Physician Name ............................................................................. 21 10.4.5 Loop 2310D Rendering Provider Name ........................................................................................ 22 10.4.6 Loop 2310E Service Facility Location ........................................................................................... 22 10.4.7 Loop 2310F Referring Provider Name .......................................................................................... 22 10.4.8 Loop 2320 Other Subscriber Information .................................................................................... 23 10.4.9 Loop 2330A Other Subscriber Name ............................................................................................ 23 10.4.10 Loop 2330B Other Payer Name .................................................................................................. 24 10.4.11 Loop 2400 Service Line Number................................................................................................. 24 10.4.12 Loop 2410 Drug Identification .................................................................................................... 25 10.4.13 Loop 2420A Operating Physician Name ..................................................................................... 26 10.4.14 Loop 2420B Other Operating Physician Name ........................................................................... 26 10.4.15 Loop 2420C Rendering Provider Name ...................................................................................... 26 10.4.16 Loop 2420D Referring Provider Name ....................................................................................... 26 10.4.17 Loop 2430 Line Adjudication Information .................................................................................. 27 10.4.18 Transaction Set Trailer ............................................................................................................... 27 11 Appendices .................................................................................................................................................... 28 11.1 Implementation Checklist ..................................................................................................................... 28 11.2 Transmission Examples.......................................................................................................................... 28 11.3 Frequently Asked Questions.................................................................................................................. 28 11.4 Acronym Listing ..................................................................................................................................... 29 11.5 Change Summary ................................................................................................................................... 31 List of Tables Table 1. EDI Transactions and Code Set References ............................................................................................... 2 Table 2. Additional EDI Resources .......................................................................................................................... 3 Table 3. ISA Interchange Control Header ............................................................................................................. 11 Table 4. CGS Delimiters ......................................................................................................................................... 12 CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. vi Table 5. Segment / Elements Not Accepted by Medicare .................................................................................... 13 Table 6. Header and Information Source .............................................................................................................. 16 Table 7. Loop 1000A NM1 Submitter Name ......................................................................................................... 16 Table 8. Loop 1000B NM1 Receiver Name ........................................................................................................... 17 Table 9. Loop 2010AA Billing Provider .................................................................................................................. 17 Table 10. Loop 2000B Subscriber Hierarchical Level ............................................................................................ 18 Table 11. Loop 2010BA Subscriber Name ............................................................................................................. 18 Table 12. Loop 2010BB Payer Name ..................................................................................................................... 19 Table 13. Loop 2300 Claim Information ............................................................................................................... 20 Table 14. Loop 2310A Attending Provider Name ................................................................................................. 21 Table 15. Loop 2310B Operating Physician Name ................................................................................................ 21 Table 16. Loop 2310C Other Operating Physician Name ..................................................................................... 21 Table 17. Loop 2310D Rendering Provider Name ................................................................................................ 22 Table 18. Loop 2310E Service Facility Location .................................................................................................... 22 Table 19. Loop 2310F Referring Provider Name ................................................................................................... 22 Table 20. Loop 2320 Other Subscriber Information ............................................................................................. 23 Table 21. Loop 2330A Other Subscriber Name .................................................................................................... 23 Table 22. Loop 2330B Other Payer Name............................................................................................................. 24 Table 23. Loop 2400 Service Line Number ........................................................................................................... 24 Table 24. Loop 2410 Drug Identification .............................................................................................................. 25 Table 25. Loop 2420A Operating Physician Name ................................................................................................ 26 Table 26. Loop 2420B Other Operating Physician Name ..................................................................................... 26 Table 27. Loop 2420C Rendering Provider Name ................................................................................................. 26 Table 28. Loop 2420D Referring Provider Name .................................................................................................. 27 Table 29. Loop 2430 Line Adjudication Information ............................................................................................ 27 Table 30. Transaction Set Trailer .......................................................................................................................... 27 Table 31. Acronyms Listing and Definitions .......................................................................................................... 29 Table 32. Companion Guide Version History ........................................................................................................ 31 CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. vii List of Figures Figure 1. GPNet V5010 Test 837 Claims Transaction Flow ..................................................................................... 7 Figure 2. GPNet V5010 837 Claims Transaction Flow ............................................................................................. 8 Figure 3. Example of the 837I Control Segments and Envelopes ......................................................................... 28 CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 1 1 Introduction This document is intended to provide information from the author of this guide to Trading Partners to give them the information they need to exchange Electronic Data Interchange (EDI) data with the author. This includes information about registration, testing, support, and specific information about control record setup. An EDI Trading Partner is defined as any Medicare customer (e.g., provider/supplier, billing service, clearinghouse, or software vendor) that transmits to, or receives electronic data from Medicare. Medicare’s EDI transaction system supports transactions adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) as well as additional supporting transactions as described in this guide. Medicare Fee-For-Service (FFS) is publishing this Companion Guide (CG) to clarify, supplement, and further define specific data content requirements to be used in conjunction with, and not in place of, the ASC X12N Technical Report Type 3 (TR3) Version 005010 and associated errata mandated by HIPAA and/or adopted by Medicare FFS for EDI. This CG provides communication, connectivity, and transaction-specific information to Medicare FFS Trading Partners and serves as the authoritative source for Medicare FFS-specific EDI protocols. Additional information on Medicare FFS EDI practices are referenced within Internet-only Manual (IOM) Pub. 100-04 Medicare Claims Processing Manual: • Chapter 24 – General EDI and EDI Support, Requirements, Electronic Claims, and Mandatory Electronic Filing of Medicare Claims (https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/clm104c24.pdf) 1.1 Scope EDI addresses how Trading Partners exchange professional and institutional claims, claim acknowledgments, claim remittance advice, claim status inquiry and responses, and eligibility inquiry and responses electronically with Medicare. This CG also applies to ASC X12N 837I transactions that are being exchanged with Medicare by third parties, such as clearinghouses, billing services or network service vendors. This CG provides technical and connectivity specification for the 837 Health Care Claim: Institutional transaction Version 005010X223A2. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 2 1.2 Overview This CG includes information needed to commence and maintain communication exchange with Medicare. In addition, this CG has been written to assist you in designing and implementing the ASC X12N 837I transaction standard to meet Medicare’s processing standards. This information is organized in the sections listed below: • Getting Started: This section includes information related to hours of operation, and data services. Information concerning Trading Partner registration and the Trading Partner testing process is also included in this section. • Testing and Certification Requirements: This section includes detailed transaction testing information as well as certification requirements needed to complete transaction testing with Medicare. • Connectivity/Communications: This section includes information on Medicare’s transmission procedures as well as communication and security protocols. • Contact Information: This section includes EDI customer service, EDI technical assistance, Trading Partner services and applicable websites. • Control Segments/Envelopes: This section contains information needed to create the Interchange Control Header/Trailer (ISA/IEA), Functional Group Header/Trailer (GS/GE), and Transaction Set Header/Trailer (ST/SE) control segments for transactions to be submitted to or received from Medicare. • Specific Business Rules and Limitations: This section contains Medicare business rules and limitations specific to the ASC X12N 837I. • Acknowledgments and Reports: This section contains information on all transaction acknowledgments sent by Medicare and report inventory. • Trading Partner Agreement: This section contains information related to implementation checklists, transmission examples, Trading Partner Agreements and other resources. • Transaction Specific Information: This section describes the specific CMS requirements over and above the information in the ASC X12N 837I TR3. 1.3 References The following locations provide information for where to obtain documentation for Medicare-adopted EDI transactions and code sets. Table 1. EDI Transactions and Code Set References Resource Location ASC X12N TR3s The official ASC X12 website Washington Publishing Company Health Care Code Sets The official Washington Publishing Company website CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 3 1.4 Additional Information The websites in the following table provide additional resources for HIPAA Version 005010A1 implementation: Table 2. Additional EDI Resources Resource Web Address Medicare FFS EDI Operations https://www.cms.gov/ElectronicBillingEDITrans/ 2 Getting Started 2.1 Working Together CGS Administrators, LLC (CGS) is dedicated to providing communication channels to ensure communication remains constant and efficient. CGS has several options to assist the community with their electronic data exchange needs. By using any of these methods CGS is focused on supplying the Trading Partner community with a variety of support tools. An EDI help desk is established for the first point of contact for basic information and troubleshooting. The help desk is available to support most EDI questions/incidents while at the same time being structured to triage each incident if more advanced research is needed. Email is also accessible as a method of communicating with CGS EDI. The email account is monitored by knowledgeable staff ready to assist you. When communicating via email, please exclude any protected health information (PHI) to ensure security is maintained. In addition to the CGS EDI help desk and email access, see Section 5 for additional contact information. CGS also has several external communication components in place to reach out to the Trading Partner community. CGS posts all critical updates, system issues and EDI-specific billing material to their website, (https://www.cgsmedicare.com/). All Trading Partners are encouraged to visit this page to ensure familiarity with the content of the site. CGS also distributes EDI pertinent information in the form of an EDI newsletter or comparable publication, which is posted to the website every three months. In addition to the website, a	837I_compguide.pdf
in this section. • Testing and Certification Requirements: This section includes detailed transaction testing information as well as certification requirements needed to complete transaction testing with Medicare. • Connectivity/Communications: This section includes information on Medicare’s transmission procedures as well as communication and security protocols. • Contact Information: This section includes EDI customer service, EDI technical assistance, Trading Partner services and applicable websites. • Control Segments/Envelopes: This section contains information needed to create the Interchange Control Header/Trailer (ISA/IEA), Functional Group Header/Trailer (GS/GE), and Transaction Set Header/Trailer (ST/SE) control segments for transactions to be submitted to or received from Medicare. • Specific Business Rules and Limitations: This section contains Medicare business rules and limitations specific to the ASC X12N 837I. • Acknowledgments and Reports: This section contains information on all transaction acknowledgments sent by Medicare and report inventory. • Trading Partner Agreement: This section contains information related to implementation checklists, transmission examples, Trading Partner Agreements and other resources. • Transaction Specific Information: This section describes the specific CMS requirements over and above the information in the ASC X12N 837I TR3. 1.3 References The following locations provide information for where to obtain documentation for Medicare-adopted EDI transactions and code sets. Table 1. EDI Transactions and Code Set References Resource Location ASC X12N TR3s The official ASC X12 website Washington Publishing Company Health Care Code Sets The official Washington Publishing Company website CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 3 1.4 Additional Information The websites in the following table provide additional resources for HIPAA Version 005010A1 implementation: Table 2. Additional EDI Resources Resource Web Address Medicare FFS EDI Operations https://www.cms.gov/ElectronicBillingEDITrans/ 2 Getting Started 2.1 Working Together CGS Administrators, LLC (CGS) is dedicated to providing communication channels to ensure communication remains constant and efficient. CGS has several options to assist the community with their electronic data exchange needs. By using any of these methods CGS is focused on supplying the Trading Partner community with a variety of support tools. An EDI help desk is established for the first point of contact for basic information and troubleshooting. The help desk is available to support most EDI questions/incidents while at the same time being structured to triage each incident if more advanced research is needed. Email is also accessible as a method of communicating with CGS EDI. The email account is monitored by knowledgeable staff ready to assist you. When communicating via email, please exclude any protected health information (PHI) to ensure security is maintained. In addition to the CGS EDI help desk and email access, see Section 5 for additional contact information. CGS also has several external communication components in place to reach out to the Trading Partner community. CGS posts all critical updates, system issues and EDI-specific billing material to their website, (https://www.cgsmedicare.com/). All Trading Partners are encouraged to visit this page to ensure familiarity with the content of the site. CGS also distributes EDI pertinent information in the form of an EDI newsletter or comparable publication, which is posted to the website every three months. In addition to the website, a distribution list (https://www.cgsmedicare.com/medicare_dynamic/ls/001.asp) has been established in order to broadcast urgent messages. 2.2 Trading Partner Registration An EDI Trading Partner is any entity (provider, billing service, clearinghouse, software vendor, employer group, financial institution, etc.) that transmits electronic data to, or receives electronic data from, another entity. Medicare FFS and CGS support many different types of Trading Partners or customers for EDI. To ensure proper registration, it is important to understand the terminology associated with each customer type: CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 4 • Submitter – the entity that owns the submitter ID associated with the health care data being submitted. It is most likely the provider, hospital, clinic, supplier, etc., but could also be a third party submitting on behalf of one of these entities. However, a submitter must be directly linked to each billing National Provider Identifier (NPI). Often the terms submitter and Trading Partner are used interchangeably because a Trading Partner is defined as the entity engaged in the exchange or transmission of electronic transactions. Thus, the entity that is submitting electronic administrative transactions to CGS is a Medicare FFS Trading Partner. • Vendor – an entity that provides hardware, software, and/or ongoing technical support for covered entities. In EDI, a vendor can be classified as a software vendor, billing or network service vendor, or clearinghouse. • Software Vendor – an entity that creates software used by Trading Partners to conduct the exchange of electronic transactions with Medicare FFS. • Billing Service – a third party that prepares and/or submits claims for a provider. • Clearinghouse – a third party that submits and/or exchanges electronic transactions (claims, claim status or eligibility inquiries, remittance advice, etc.) on behalf of a provider. • Network Service Vendor – a third party that provides connectivity between a Trading Partner and CGS. Medicare requires all trading partners to complete an EDI enrollment form and sign an EDI agreement. The EDI enrollment form (https://www.cgsmedicare.com/parta/edi/index.html) designates the Medicare contractor the entity agrees to engage in EDI and ensures agreement between parties to implement standard policies and practices to ensure the security and integrity of the information being exchanged. Entities processing paper do not need to complete an EDI registration. Under HIPAA, EDI applies to all covered entities transmitting the following HIPAA-established administrative transactions: 837I and 837P, 835, 270/271, 276/277, and the National Council for Prescription Drug Programs (NCPDP) D.0. Additionally, Medicare Administrative Contractors (MACs) and Common Electronic Data Interchange (CEDI) will use the Interchange Acknowledgment (TA1), Implementation Acknowledgment (999), and 277 Claim Acknowledgement (277CA) error-handling transactions. Medicare requires that CGS furnish information on EDI to new Trading Partners that request Medicare claim privileges. Additionally, Medicare requires CGS to assess the capability of entities to submit data electronically, establish their qualifications (see test requirements in Section 3), and enroll and assign submitter EDI identification numbers to those approved to use EDI. A provider must obtain an NPI and furnish that NPI to CGS prior to completion of an initial EDI Enrollment Agreement and issuance of an initial EDI number and password by that contractor. CGS is required to verify that NPI is on the Provider Enrollment Chain and Ownership System (PECOS). If the NPI is not verified on the PECOS, the EDI Enrollment Agreement is denied, and the provider is encouraged to contact the appropriate MAC provider enrollment department (for Medicare Part A and Part B provider) or the National Supplier Clearinghouse (for Durable Medical Equipment suppliers) to resolve the issue. Once the NPI is properly verified, the provider can reapply the EDI Enrollment Agreement. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 5 A provider’s EDI number and password serve as an electronic signature and the provider would be liable for any improper usage or illegal action performed with it. A provider’s EDI access number and password are not part of the capital property of the provider’s operation and may not be given to a new owner of the provider’s operation. A new owner must obtain their own EDI access number and password. If providers elect to submit/receive transactions electronically using a third party such as a billing agent, a clearinghouse, or network services vendor, then the provider is required to have an agreement signed by that third party. The third party must agree to meet the same Medicare security and privacy requirements that apply to the provider in regard to viewing or using Medicare beneficiary data. These agreements are not to be submitted to Medicare but are to be retained by the provider. Providers will notify CGS which third party agents they will be using on their EDI Enrollment form. Third parties are required to register with CGS by completing the third-party agreement form. This will ensure that their connectivity is completed properly, however they may need to enroll in mailing lists separately in order to receive all publications and email notifications. Additional third-party billing information can be found at (https://www.cgsmedicare.com/parta/edi/enrollment.html). The providers must also be informed that they are not permitted to share their personal EDI access number and password with any billing agent, clearinghouse, or network service vendor. Providers must also not share their personal EDI access number with anyone on their own staff who does not need to see the data for completion of a valid electronic claim, to process a remittance advice for a claim, to verify beneficiary eligibility, or to determine the status of a claim. No other non-staff individuals or entities may be permitted to use a Provider’s EDI number and password to access Medicare systems. Clearinghouse and other third-party representatives must obtain and use their own unique EDI access number and password from CGS. For a complete reference to security requirements, see Section 4.4. 2.3 Trading Partner Certification and Testing Process Medicare FFS requires all Trading Partners to send a test file containing at least 25 claims, which are representative of their practice or services. To begin the testing and certification process, trading partners should complete the J15 Communications and the enrollment form (https://www.cgsmedicare.com/parta/edi/enrollment.html). Once CGS provides the Submitter ID to a trading partner a test file should be submitted to CGS containing at least 25 claims with a T in the ISA15. Description of delivery and interpretation of results. Once the test file is submitted, verify the file received an accepted 999 and 277CA. Once an error free 277CA populates the EDI helpdesk should be contacted to move the submitter ID into production. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 6 3 Testing and Certification Requirements 3.1 Testing Requirements All submitters must produce accurate electronic test files before being allowed to submit claim transactions in production. Test claims are subject to ASC X12N standard syntax and TR3 semantic data edits. Documentation will be provided when this process detects errors. • Standard syntax testing validates the programming of the incoming file and includes file layout, record sequencing, balancing, alpha-numeric/numeric/date file conventions, field values, and relational edits. Test files must pass 100 percent of the standard syntax tests before submission to production is approved. • TR3 Semantic Data testing validates data required for claims processing, e.g., procedure/ diagnosis codes, modifiers. A submitter must demonstrate, at a minimum, 95 percent accuracy rate in data testing before submission in production is approved where, in the judgment of CGS, the vendor/submitter will make the necessary correction(s) prior to submitting a production file. For MACs, the minimum 95 percent accuracy rate includes the front-end edits applied implementation guide editing module (https://www.cgsmedicare.com/parta/edi/index.html). o Test results will be provided to the submitter within three business days; during HIPAA version transitions this time period may be extended, not to exceed ten business days. Many submitters use the same software, or the same clearinghouse to submit their electronic transactions to Medicare. Once a vendor or clearinghouse passes the testing process, clients of that entity using the approved software will not be required to test prior to being migrated to production. If a vendor or clearinghouse supports multiple software products, each product will require testing. Third party agents who have passed testing will be required to provide CGS with their client migration schedule. Trading Partners who submit transactions directly to more than one A/B MAC must contact each A/B MAC with whom they exchange EDI transactions to inquire about the need for supplemental testing whenever they plan to begin to use an additional EDI transaction, different or significantly modified software for submission of a previously used EDI transaction, or before a billing agent or clearinghouse begins to submit transactions on behalf of an additional Trading Partner. The individual A/B MAC may need to retest at that time to re- establish compatibility and accuracy, particularly if there will also be a change in the telecommunication connection to be used. Billing services and clearinghouses are not permitted to begin to submit or receive EDI transactions on behalf of a Provider prior to submission of written authorization by the Trading Partner that the billing agent or clearinghouse has been authorized to handle those transactions on the provider’s behalf. See Section 2.2 for further information on EDI enrollment. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC.	837I_compguide.pdf
submitted to CGS containing at least 25 claims with a T in the ISA15. Description of delivery and interpretation of results. Once the test file is submitted, verify the file received an accepted 999 and 277CA. Once an error free 277CA populates the EDI helpdesk should be contacted to move the submitter ID into production. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 6 3 Testing and Certification Requirements 3.1 Testing Requirements All submitters must produce accurate electronic test files before being allowed to submit claim transactions in production. Test claims are subject to ASC X12N standard syntax and TR3 semantic data edits. Documentation will be provided when this process detects errors. • Standard syntax testing validates the programming of the incoming file and includes file layout, record sequencing, balancing, alpha-numeric/numeric/date file conventions, field values, and relational edits. Test files must pass 100 percent of the standard syntax tests before submission to production is approved. • TR3 Semantic Data testing validates data required for claims processing, e.g., procedure/ diagnosis codes, modifiers. A submitter must demonstrate, at a minimum, 95 percent accuracy rate in data testing before submission in production is approved where, in the judgment of CGS, the vendor/submitter will make the necessary correction(s) prior to submitting a production file. For MACs, the minimum 95 percent accuracy rate includes the front-end edits applied implementation guide editing module (https://www.cgsmedicare.com/parta/edi/index.html). o Test results will be provided to the submitter within three business days; during HIPAA version transitions this time period may be extended, not to exceed ten business days. Many submitters use the same software, or the same clearinghouse to submit their electronic transactions to Medicare. Once a vendor or clearinghouse passes the testing process, clients of that entity using the approved software will not be required to test prior to being migrated to production. If a vendor or clearinghouse supports multiple software products, each product will require testing. Third party agents who have passed testing will be required to provide CGS with their client migration schedule. Trading Partners who submit transactions directly to more than one A/B MAC must contact each A/B MAC with whom they exchange EDI transactions to inquire about the need for supplemental testing whenever they plan to begin to use an additional EDI transaction, different or significantly modified software for submission of a previously used EDI transaction, or before a billing agent or clearinghouse begins to submit transactions on behalf of an additional Trading Partner. The individual A/B MAC may need to retest at that time to re- establish compatibility and accuracy, particularly if there will also be a change in the telecommunication connection to be used. Billing services and clearinghouses are not permitted to begin to submit or receive EDI transactions on behalf of a Provider prior to submission of written authorization by the Trading Partner that the billing agent or clearinghouse has been authorized to handle those transactions on the provider’s behalf. See Section 2.2 for further information on EDI enrollment. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 7 3.2 Certification Requirements Medicare FFS does not certify Trading Partners. However, CGS does certify vendors, clearinghouses, and billing services by conducting testing with them and maintaining an approved vendor list. • Part A Approved Vendor List (https://www.cgsmedicare.com/parta/edi/index.html) • Home Health & Hospice Vendor List (https://www.cgsmedicare.com/hhh/edi/index.html) 4 Connectivity / Communications 4.1 Process Flows The following diagram illustrates how ANSI ASC X12 electronic transactions flow into and out of GPNet, CGS/Palmetto GBA’s EDI Gateway. Figure 1. GPNet V5010 Test 837 Claims Transaction Flow CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 8 Figure 2. GPNet V5010 837 Claims Transaction Flow 4.2 Transmission Please see the GPNet Communications Manual and Connectivity Specifications posted under Manuals and User Guides (https://www.cgsmedicare.com/parta/edi/manuals.html) 4.2.1 Re-transmission Procedures CGS does not require any identification of a previous transmission of a claim. All claims should be marked as original. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 9 4.3 Communication Protocol Specifications Please see the GPNet Communications Manual posted under Manuals and User Guides (https://www.cgsmedicare.com/parta/edi/manuals.html) Note: Internet connectivity is only available using our CAQH CORE connectivity method for the following transactions: • 276: ASC X12 Health Care Claim Status Request • 277: ASC X12 Health Care Information Status Notification • 835: ASC X12 Health Care Claim Payment/ Advice • 999: ASC X12 Implementation Acknowledgment For Health Care Insurance Under the internet portal demonstration, for select transaction and with prior CMS approval 4.4 Security Protocols and Passwords All Trading Partners must adhere to CMS information security policies; including, but not limited to, the transmission of electronic claims, claim status, receipt of the remittance advice, or any system access to obtain beneficiary PHI and/or eligibility information. Violation of this policy will result in revocation of all methods of system access. CGS is responsible for notifying all affected Trading Partners as well as reporting the system revocation to CMS. Password guidelines are provided with receipt of initial passwords from CGS. Please contact the EDI helpdesk for assistance with passwords and resets CMS’ information security policy strictly prohibits the sharing or loaning of Medicare assigned IDs and passwords. Users should take appropriate measures to prevent unauthorized disclosure or modification of assigned IDs and passwords. The Trading Partner should protect password privacy by limiting knowledge of the password to key personnel. The password should be changed when there are any personnel changes. The submitter ID and Password are required to transmit files to CGS. 5 Contact Information 5.1 EDI Customer Service J15- Part A/Home Health & Hospice (HHH) Correspondence CGS PO box 20018 Nashville, TN 37202 CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 10 EDI Helpdesk Numbers CGS Part A – 1-866-590-6703 Option 2 CGS Part B – 1-866-276-9558 Option 2 CGS HHH – 1-866-299-4500 Option 2 EDI Fax Numbers Ohio Part A – 1-615-664-5945 Kentucky Part A – 1-615-664-5943 Ohio Part B – 1-615-664-5927 Kentucky Part B – 1-615-664-5917 Home Health & Hospice – 1-615-664-5947 Hours of Operation and Holiday Schedule Monday – Friday 8:00 a.m. to 5:00 p.m. Eastern Time. CGS Holiday Schedule • New Year’s Day • Martin Luther King, Jr.’s Birthday • Memorial Day • Independence Day • Labor Day • Thanksgiving Day • Day after Thanksgiving • Christmas Eve • Christmas Day 5.2 EDI Technical Assistance See section 5.1 for Technical Assistance Information 5.3 Trading Partner Service Number See section 5.1 for Technical Assistance Information CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 11 5.4 Applicable Websites / Email CGS Medicare Part B Online Help (https://www.cgsmedicare.com/partb/cs/online_help.html) CGS Home Health & Hospice Online Help (https://www.cgsmedicare.com/hhh/cs/onlinehelphhh.html) CGS Medicare Part A Online Help (https://www.cgsmedicare.com/parta/cs/online_help.html) CGS Medicare Website (http://www.cgsmedicare.com) 6 Control Segments / Envelopes Enveloping information must be as follows: Note: A hyphen in the table below means N/A. Table 3. ISA Interchange Control Header Page # Element Name Codes/Content Notes/Comments C.4 ISA01 Authorization Information Qualifier 00 Medicare expects the value to be 00. C.4 ISA02 Authorization Information - ISA02 shall contain 10 blank spaces. C.4 ISA03 Security Information Qualifier 00 Medicare expects the value to be 00 and ISA04 shall contain 2 blank spaces. C.4 ISA04 Security Information - Medicare does not use Security Information and will ignore content sent in ISA04. C.4 ISA05 Interchange ID Qualifier 28, ZZ Must be “28” or “ZZ” C.4 ISA06 Interchange Sender ID - Each MAC will assign its own ID. This is also required in the GS02. C.5 ISA07 Interchange ID Qualifier 28, ZZ Must be “28” or “ZZ” C.5 ISA08 Interchange Receiver ID - Medicare Administrative Contractor (MAC) contract number for the inbound transactions. Ohio Part A 15201 Kentucky Part A 15101 Home Health & Hospice 15004 CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 12 Page # Element Name Codes/Content Notes/Comments C.5 ISA11 Repetition Separator - CGS repetition separator character. C.6 ISA14 Acknowledgement Requested 1 Medicare requires submitter to send code value 1 – Interchange Acknowledgment Requested (TA1). Medicare will only return a TA1 segment when there is an error in the ISA/IEA Interchange Envelope. C.7 GS02 Application Sender Code - Submitter number assigned by CGS C.7 GS03 Application Receiver’s Code - CGS contract number. C.7 GS04 Functional Group Creation Date - Must not be a future date C.7 GS08 Version Identifier Code 005010X223A2 Medicare expects value “005010X223A2” Interchange Control (ISA/IEA), Functional Group (GS/GE), and Transaction Set (ST/SE) envelopes must be used as described in the TR3. Medicare’s expectations for the Control Segments and Envelopes are detailed in Sections 6.1, 6.2, and 6.3. 6.1 ISA-IEA Delimiters – Inbound Transactions As detailed in the TR3, delimiters are determined by the characters sent in specified, set positions of the ISA header. For transmissions inbound to Medicare FFS, these characters are determined by the submitter and can be any characters as defined in the TR3 and must not be contained within any data elements within the ISA/IEA Interchange Envelope. Delimiters – Outbound Transactions Trading Partners should contact CGS for a list of delimiters to expect from Medicare. Note that these characters will not be used in data elements within an ISA/IEA Interchange Envelope. Table 4. CGS Delimiters Delimiter Character Used Dec Value Hex Value Data Element Separator * 42 2A Repetition Separator ^ 94 5E CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 13 Delimiter Character Used Dec Value Hex Value Component Element Separator > 62 3E Segment Terminator ~ 126 7E Inbound Data Element Detail and Explanation All data elements within the ISA/IEA interchange envelope must follow ASC X12N syntax rules as defined within the TR3. 6.2 GS-GE Functional group (GS-GE) codes are transaction specific. Therefore, information concerning the GS/GE Functional Group Envelope can be found in Table 3. 6.3 ST-SE Medicare FFS follows the HIPAA-adopted TR3 requirements. 7 Specific Business Rules This section describes the specific CMS requirements over and above the standard information in the TR3. 7.1 General Notes Errors identified for business level edits performed prior to the Subscriber loop (2000B) will result in immediate file failure at that point. When this occurs, no further editing will be performed beyond the point of failure. The billing provider must be associated with an approved electronic submitter. Claims submitted for billing providers that are not associated to an approved electronic submitter will be rejected. The following table describes segments/ elements not accepted by Medicare. Note: A hyphen in the table below means N/A. Table 5. Segment / Elements Not Accepted by Medicare Page # Loop ID Reference Name Codes/Content Notes/Comments 81 2000A CUR Foreign Currency Information - Medicare does not support the submission of foreign currency. 99 2010AC Loop Rule Pay to Plan Loop - Must not be present. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 14 Page # Loop ID Reference Name Codes/Content Notes/Comments 120 2010BA REF Subscriber Secondary Identification (REF01 = “SY”) - Must not be present. 127 2010BB REF Payer Secondary Identification - Must not be present. 131 2000C Loop Rule Patient Hierarchical Level - Must not be present. For Medicare, the subscriber is always the same as the patient. 158 2300 CN1 Contract Information - Must not be present. 396 2330C Loop Rule Other Payer Attending Provider - Must not be present. 400 2330D Loop Rule Other Payer Operating Physician - Must not be present. 404 2330E Loop Rule Other Payer Other Operating Physician - Must not be present. 408 2330F Loop Rule Other Payer Service Facility Location - Must not be present. 412 2330G Loop Rule Other Payer Rendering Provider Name - Must not be present. 416 2330H Loop Rule Other Payer Referring Provider - Must not be present. 420 2330I Loop Rule Other Payer Billing Provider - Must not be present. 8 Acknowledgments and Reports CGS will provide acknowledgments and reports for submitted X12 version 005010 transactions. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 15 Medicare has adopted three acknowledgement transactions with the Version 005010 implementation: the 277CA, the TA1, and the 999. These acknowledgments will replace proprietary reports previously provided by the MACs. Medicare FFS has adopted a process to only reject claim submissions that are out of compliance with the ASC X12N Version 005010 standard; the appropriate	837I_compguide.pdf
Used Dec Value Hex Value Data Element Separator * 42 2A Repetition Separator ^ 94 5E CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 13 Delimiter Character Used Dec Value Hex Value Component Element Separator > 62 3E Segment Terminator ~ 126 7E Inbound Data Element Detail and Explanation All data elements within the ISA/IEA interchange envelope must follow ASC X12N syntax rules as defined within the TR3. 6.2 GS-GE Functional group (GS-GE) codes are transaction specific. Therefore, information concerning the GS/GE Functional Group Envelope can be found in Table 3. 6.3 ST-SE Medicare FFS follows the HIPAA-adopted TR3 requirements. 7 Specific Business Rules This section describes the specific CMS requirements over and above the standard information in the TR3. 7.1 General Notes Errors identified for business level edits performed prior to the Subscriber loop (2000B) will result in immediate file failure at that point. When this occurs, no further editing will be performed beyond the point of failure. The billing provider must be associated with an approved electronic submitter. Claims submitted for billing providers that are not associated to an approved electronic submitter will be rejected. The following table describes segments/ elements not accepted by Medicare. Note: A hyphen in the table below means N/A. Table 5. Segment / Elements Not Accepted by Medicare Page # Loop ID Reference Name Codes/Content Notes/Comments 81 2000A CUR Foreign Currency Information - Medicare does not support the submission of foreign currency. 99 2010AC Loop Rule Pay to Plan Loop - Must not be present. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 14 Page # Loop ID Reference Name Codes/Content Notes/Comments 120 2010BA REF Subscriber Secondary Identification (REF01 = “SY”) - Must not be present. 127 2010BB REF Payer Secondary Identification - Must not be present. 131 2000C Loop Rule Patient Hierarchical Level - Must not be present. For Medicare, the subscriber is always the same as the patient. 158 2300 CN1 Contract Information - Must not be present. 396 2330C Loop Rule Other Payer Attending Provider - Must not be present. 400 2330D Loop Rule Other Payer Operating Physician - Must not be present. 404 2330E Loop Rule Other Payer Other Operating Physician - Must not be present. 408 2330F Loop Rule Other Payer Service Facility Location - Must not be present. 412 2330G Loop Rule Other Payer Rendering Provider Name - Must not be present. 416 2330H Loop Rule Other Payer Referring Provider - Must not be present. 420 2330I Loop Rule Other Payer Billing Provider - Must not be present. 8 Acknowledgments and Reports CGS will provide acknowledgments and reports for submitted X12 version 005010 transactions. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 15 Medicare has adopted three acknowledgement transactions with the Version 005010 implementation: the 277CA, the TA1, and the 999. These acknowledgments will replace proprietary reports previously provided by the MACs. Medicare FFS has adopted a process to only reject claim submissions that are out of compliance with the ASC X12N Version 005010 standard; the appropriate response for such errors will be returned on a 999. Batch submissions with errors will not be rejected in totality, unless warranted. 8.1 Report Inventory CGS does not provide any proprietary acknowledgments. 9 Trading Partner Agreement EDI Trading Partner Agreements ensure the integrity of the electronic transaction process. The Trading Partner Agreement is related to the electronic exchange of information, whether the agreement is an entity or a part of a larger agreement, between each party to the agreement. Medicare FFS requires all Trading Partners to sign a Trading Partner Agreement with CGS. This agreement can be found on the CGS website (https://www.cgsmedicare.com/parta/edi/index.html). Additionally, CGS requires the following: The CGS Trading Partner Agreement process is identical to our EDI enrollment and registration process. 10 Transaction-Specific Information This section defines specific CMS requirements over and above the standard information in the ASC X12N 837I TR3. 10.1 Header The following sub-sections contain specific details associated with header. 10.1.1 Header and Information Source The following tables define the specific details associated with Header and Information Source: Note: A hyphen in the table below means N/A. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 16 Table 6. Header and Information Source Page # Loop ID Reference Name Codes/Content Length Notes/Comments 67 - ST02 Transaction Set Control Number - 9 The MAC will reject an interchange (transmission) that is not submitted with unique values in the ST02 (Transaction Set Control Number) elements. 68 - BHT02 Transaction Set Purpose Code 00 2 Must equal “00” (ORIGINAL). 69 - BHT06 Claim/Encounter Identifier CH 2 Must equal “CH” (CHARGEABLE). 10.1.2 Loop 1000A Submitter Name The following table defines the specific details associated with Loop 1000A Submitter Name: Note: A hyphen in the table below means N/A. Table 7. Loop 1000A NM1 Submitter Name Page # Loop ID Reference Name Codes/Content Length Notes/Comments 72 1000A NM105 Submitter Middle Name or Initial - 25 The first position must be alphabetic (A-Z). 72 1000A NM109 Submitter ID - 80 The MAC will reject an interchange (transmission) that is submitted with a submitter identification number that is not authorized for electronic claim submission. Submitter ID must match the value submitted in ISA06 and GS02. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 17 10.1.3 Loop 1000B Receiver Name The following table defines the specific details associated with Loop 1000B Receiver Name: Note: A hyphen in the table below means N/A. Table 8. Loop 1000B NM1 Receiver Name Page # Loop ID Reference Name Codes/Content Length Notes/Comments 77 1000B NM103 Receiver Name - 60 - 77 1000B NM109 Receiver Primary Identifier - 80 The MAC will reject an interchange (transmission) that is not submitted with a valid Part A MAC code. Each individual MAC determines this identifier. Submitter ID must match the value submitted in ISA08 and GS03. 10.2 Billing Provider 10.2.1 Loop 2010AA Billing Provider The following table defines the specific details associated with Loop 2010AA Billing Provider: Note: A hyphen in the table below means N/A. Table 9. Loop 2010AA Billing Provider Page # Loop ID Reference Name Codes/Content Length Notes/Comments 89 2010AA N403 Billing Provider Postal Code - 15 When the postal code does not include a +4 value, use 9998. 10.3 Subscriber Detail The following sub-sections contain specific requirements for the Subscriber Detail. 10.3.1 Loop 2000B Subscriber Hierarchical Level The following table defines the specific details associated with Loop 2000B Subscriber Hierarchical Level. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 18 Table 10. Loop 2000B Subscriber Hierarchical Level Page # Loop ID Reference Name Codes/Content Length Notes/Comments 108 2000B HL04 Hierarchical Child Code 0 1 The value accepted is “0”. 109 2000B SBR01 Payer Responsibilit y Sequence Number Code P, S, T 1 The values accepted are “P” or “S” or “T”. 110 2000B SBR02 Individual Relationship Code 18 2 For Medicare, the subscriber is always the same as the patient. 110 2000B SBR09 Claim Filing Indicator Code MA 2 For Medicare, the subscriber is always the same as the patient. 10.3.2 Loop 2010BA Subscriber Name The following table defines the specific details associated with Loop 2010BA Subscriber Name. Note: A hyphen in the table below means N/A. Table 11. Loop 2010BA Subscriber Name Page # Loop ID Reference Name Codes/Content Length Notes/Comments 113 2010BA NM102 Subscriber Entity Type Qualifier 1 1 The value accepted is “1”. 113 2010BA NM105 Subscriber Middle Name or Initial - 25 The first position must be alphabetic (A-Z). 114 2010BA NM108 Subscriber Identification Code Qualifier MI 2 The value accepted is “MI”. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 19 Page # Loop ID Reference Name Codes/Content Length Notes/Comments 114 2010BA NM109 Subscriber Primary Identifier - 80 The MBI: must be 11 positions in the format of C A AN N A AN N A A N N where “C” represents a constrained numeric 1 thru 9, “A” represents alphabetic character A – Z but excluding S, L, O, I, B, Z, “N” represents numeric 0 thru 9, and “AN” represents either “A” or “N”. 118 2010BA DMG02 Subscriber Birth Date - 35 Must not be a future date. 10.3.3 Loop 2010BB Payer Name The following table defines the specific details associated with Loop 2010BB Payer Name. Table 12. Loop 2010BB Payer Name Page # Loop ID Reference Name Codes/Content Length Notes/Comments 113 2010BB NM108 Payer Identification Code Qualifier PI 2 The value accepted is “PI”. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 20 10.4 Patient Detail The following sub-sections contain specific details associated with Patient Detail. 10.4.1 Loop 2300 Claim Information The following tables define the specific details associated with Loop 2300 Claim Information. Note: A hyphen in the table below means N/A. Table 13. Loop 2300 Claim Information Page # Loop ID Reference Name Codes/Content Length Notes/Comments 144 2300 CLM01 Patient Control Number - 38 Only 20 characters will be stored and returned by Medicare. 145 2300 CLM02 Total Claim Charge Amount - 10 When Medicare is primary payer, CLM02 must equal the sum of all SV203 service line charge amounts. When Medicare is Secondary or Tertiary payer, Total Submitted Charges (CLM02) must equal the sum of all 2320 & 2430 CAS amounts and the 2320 AMT02 (AMT01= “D”). 147 2300 CLM20 Delay Reason Code - 2 Data submitted in CLM20 will not be used for processing. 148 2300 DTP03 Admission Date - - Must not be a future date. 149 2300 DTP03 Discharge Hour - - Must be in format HHMM.MM - 2300 PWK Claim Supplement Information - - Only the first iteration of the PWK, at either the claim level and/or line level, will be considered in the claim adjudication. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 21 Page # Loop ID Reference Name Codes/Content Length Notes/Comments 156 2300 PWK02 Attachment Transmission Code BM, FX, FT, EL 2 Must be “BM”, “FX”, “FT”, or “EL”. 10.4.2 Loop 2310A Attending Provider Name The following tables define the specific details associated with Loop 2310A Attending Provider Name. Note: A hyphen in the table below means N/A. Table 14. Loop 2310A Attending Provider Name Page # Loop ID Reference Name Codes/Content Length Notes/Comments 320 2310A NM105 Attending Provider Middle Name - 25 The first position must be alphabetic (A-Z). 10.4.3 Loop 2310B Operating Physician Name The following table defines the specific details associated with Loop 2310B Operating Physician Name. Note: A hyphen in the table below means N/A. Table 15. Loop 2310B Operating Physician Name Page # Loop ID Reference Name Codes/Content Length Notes/Comments 327 2310B NM105 Operating Physician Middle Name - 25 The first position must be alphabetic (A-Z). 10.4.4 Loop 2310C Other Operating Physician Name The following table defines the specific details associated with Loop 2310C Other Operating Physician Name. Note: A hyphen in the table below means N/A. Table 16. Loop 2310C Other Operating Physician Name Page # Loop ID Reference Name Codes/Content Length Notes/Comments 332 2310C NM105 Other Operating Physician Middle Name - 25 The first position must be alphabetic (A-Z). CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 22 10.4.5 Loop 2310D Rendering Provider Name The following table defines the specific details associated with Loop 2310D Rendering Provider Name. Note: A hyphen in the table below means N/A. Table 17. Loop 2310D Rendering Provider Name Page # Loop ID Reference Name Codes/Content Length Notes/Comments 337 2310D NM105 Rendering Provider Middle Name - 25 The first position must be alphabetic (A-Z). 10.4.6 Loop 2310E Service Facility Location The following table defines the specific details associated with Loop 2310E Service Facility Location. Note: A hyphen in the table below means N/A. Table 18. Loop 2310E Service Facility Location Page # Loop ID Reference Name Codes/Content Length Notes/Comments 346 2310E N403 Service Facility Location Postal Code - 15 When the postal code does not include a +4 value, use 9998. 10.4.7 Loop 2310F Referring Provider Name The following table defines the specific details associated with Loop 2310F Referring Provider Name. Note: A hyphen in the table below means N/A. Table 19. Loop 2310F Referring Provider Name Page # Loop ID Reference Name Codes/Content Length	837I_compguide.pdf
Medicare is Secondary or Tertiary payer, Total Submitted Charges (CLM02) must equal the sum of all 2320 & 2430 CAS amounts and the 2320 AMT02 (AMT01= “D”). 147 2300 CLM20 Delay Reason Code - 2 Data submitted in CLM20 will not be used for processing. 148 2300 DTP03 Admission Date - - Must not be a future date. 149 2300 DTP03 Discharge Hour - - Must be in format HHMM.MM - 2300 PWK Claim Supplement Information - - Only the first iteration of the PWK, at either the claim level and/or line level, will be considered in the claim adjudication. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 21 Page # Loop ID Reference Name Codes/Content Length Notes/Comments 156 2300 PWK02 Attachment Transmission Code BM, FX, FT, EL 2 Must be “BM”, “FX”, “FT”, or “EL”. 10.4.2 Loop 2310A Attending Provider Name The following tables define the specific details associated with Loop 2310A Attending Provider Name. Note: A hyphen in the table below means N/A. Table 14. Loop 2310A Attending Provider Name Page # Loop ID Reference Name Codes/Content Length Notes/Comments 320 2310A NM105 Attending Provider Middle Name - 25 The first position must be alphabetic (A-Z). 10.4.3 Loop 2310B Operating Physician Name The following table defines the specific details associated with Loop 2310B Operating Physician Name. Note: A hyphen in the table below means N/A. Table 15. Loop 2310B Operating Physician Name Page # Loop ID Reference Name Codes/Content Length Notes/Comments 327 2310B NM105 Operating Physician Middle Name - 25 The first position must be alphabetic (A-Z). 10.4.4 Loop 2310C Other Operating Physician Name The following table defines the specific details associated with Loop 2310C Other Operating Physician Name. Note: A hyphen in the table below means N/A. Table 16. Loop 2310C Other Operating Physician Name Page # Loop ID Reference Name Codes/Content Length Notes/Comments 332 2310C NM105 Other Operating Physician Middle Name - 25 The first position must be alphabetic (A-Z). CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 22 10.4.5 Loop 2310D Rendering Provider Name The following table defines the specific details associated with Loop 2310D Rendering Provider Name. Note: A hyphen in the table below means N/A. Table 17. Loop 2310D Rendering Provider Name Page # Loop ID Reference Name Codes/Content Length Notes/Comments 337 2310D NM105 Rendering Provider Middle Name - 25 The first position must be alphabetic (A-Z). 10.4.6 Loop 2310E Service Facility Location The following table defines the specific details associated with Loop 2310E Service Facility Location. Note: A hyphen in the table below means N/A. Table 18. Loop 2310E Service Facility Location Page # Loop ID Reference Name Codes/Content Length Notes/Comments 346 2310E N403 Service Facility Location Postal Code - 15 When the postal code does not include a +4 value, use 9998. 10.4.7 Loop 2310F Referring Provider Name The following table defines the specific details associated with Loop 2310F Referring Provider Name. Note: A hyphen in the table below means N/A. Table 19. Loop 2310F Referring Provider Name Page # Loop ID Reference Name Codes/Content Length Notes/Comments 350 2310F NM105 Referring Provider Middle Name - 25 The first position must be alphabetic (A-Z). 352 2310F REF Referring Provider Name Secondary Identification - - Must not be present (non- VA contractors). Submission of this segment will cause your claim to reject. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 23 10.4.8 Loop 2320 Other Subscriber Information The following table defines the specific details associated with Loop 2320 Other Subscriber Information. Note: A hyphen in the table below means N/A. Table 20. Loop 2320 Other Subscriber Information Page # Loop ID Reference Name Codes/Content Length Notes/Comments 355 2320 SBR01 Payer Responsibility Sequence Number Code - 1 The SBR must contain a different value in each iteration of the SBR01. Each value may only be used one time per claim. 356 2320 SBR09 Claim Filing Indicator Code - 2 The value cannot be “MA” or “MB”. - 2320 CAS Claim Level Adjustment - - CAS segment must not be present when 2000B SBR01 = “P”. 364 2320 AMT01 COB Payer Paid Amount D - Medicare requires that one occurrence of 2320 loop with an AMT segment where AMT01 = “D” must be present when 2000B SBR01 = “S”. 10.4.9 Loop 2330A Other Subscriber Name The following table defines the specific details associated with Loop 2330A Other Subscriber Name. Note: A hyphen in the table below means N/A. Table 21. Loop 2330A Other Subscriber Name Page # Loop ID Reference Name Codes/Content Length Notes/Comments 378 2330A NM105 Other Insured Middle Name - 25 The first position must be alphabetic (A-Z). CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 24 Page # Loop ID Reference Name Codes/Content Length Notes/Comments 383 2330A REF02 Other Insured Additional Identifier - 9 Must be 9 digits with no punctuation. First 3 digits cannot be higher than “272”. Digits 1-3, 4-5, and 6-9 cannot be zeros. 10.4.10 Loop 2330B Other Payer Name The following table defines the specific details associated with Loop 2330B Other Payer Name. Note: A hyphen in the table below means N/A. Table 22. Loop 2330B Other Payer Name Page # Loop ID Reference Name Codes/Content Length Notes/Comments 389 2330B DTP03 Adjudication or Payment Date - 35 Must not be future date. 10.4.11 Loop 2400 Service Line Number The following table defines the specific details associated with Loop 2400 Service Line Number. Note: A hyphen in the table below means N/A. Table 23. Loop 2400 Service Line Number Page # Loop ID Reference Name Codes/Content Length Notes/Comments 423 2400 LX01 Assigned Number - - LX01 must be greater than zero and less than or equal to “449”. An individual claim with service lines greater than “449” will be rejected (However, the transmission of claims will be accepted, per HIPAA). 425 2400 SV202-1 Product or Service ID Qualifier HC, HP 2 Must be “HC” or “HP”. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 25 Page # Loop ID Reference Name Codes/Content Length Notes/Comments 426 2400 SV202-2 Procedure Code - - If A0427, A0428 (with a QL modifier in SV202-3, SV202-4, SV202-5, or SV202-6), A0425, A0429, A0430, A0431, A0432, A0433, A0434, A0435, A0488, or A0436 (non- scheduled transportation claim) are the only codes present, 2310A NM1 must not be preset. Otherwise, 2310A NM1 must be present. 427 2400 SV203 Line Item Charge Amount - 10 SV203 must be greater than zero. SV203’s decimal positions are limited to 0, 1, or 2. 428 2400 SV205 Quantity - 15 SV205 must be greater than zero and less than or equal to “999,999.9”. Must be 0 or 1 decimal position. 434 2400 DTP03 Service Date - 35 Must not be a future date, except for type of bill 0322 after 1/1/2021 10.4.12 Loop 2410 Drug Identification The following table defines the specific details associated with Loop 2410 Drug Identification. Note: A hyphen in the table below means N/A. Table 24. Loop 2410 Drug Identification Page # Loop ID Reference Name Codes/Content Length Notes/Comments 452 2410 CTP04 National Drug Unit Count - 15 CTP04 must be greater than “0” and less than or equal to “9,999,999.999”. CTP04 is limited to up to 3 decimal positions. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 26 10.4.13 Loop 2420A Operating Physician Name The following table defines the specific details associated with Loop 2420A Operating Physician Name. Note: A hyphen in the table below means N/A. Table 25. Loop 2420A Operating Physician Name Page # Loop ID Reference Name Codes/Content Length Notes/Comments 457 2420A NM105 Operating Physician Middle Name - 25 The first position must be alphabetic (A-Z). 10.4.14 Loop 2420B Other Operating Physician Name The following table defines the specific details associated with Loop 2420B Other Operating Physician Name. Note: A hyphen in the table below means N/A. Table 26. Loop 2420B Other Operating Physician Name Page # Loop ID Reference Name Codes/Content Length Notes/Comments 462 2420B NM105 Other Operating Physician Middle Name - 25 The first position must be alphabetic (A-Z). 10.4.15 Loop 2420C Rendering Provider Name The following table defines the specific details associated with Loop 2420C Rendering Provider Name. Note: A hyphen in the table below means N/A. Table 27. Loop 2420C Rendering Provider Name Page # Loop ID Reference Name Codes/Content Length Notes/Comments 467 2420C NM105 Rendering Provider Name - 25 The first position must be alphabetic (A-Z). 10.4.16 Loop 2420D Referring Provider Name The following table defines the specific details associated with Loop 2420D Referring Provider Name. Note: A hyphen in the table below means N/A. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 27 Table 28. Loop 2420D Referring Provider Name Page # Loop ID Reference Name Codes/Content Length Notes/Comments 472 2420D NM105 Operating Physician Middle Name - 25 The first position must be alphabetic (A-Z). 10.4.17 Loop 2430 Line Adjudication Information The following table defines the specific details associated with Loop 2430 Line Adjudication Information. Note: A hyphen in the table below means N/A. Table 29. Loop 2430 Line Adjudication Information Page # Loop ID Reference Name Codes/Content Length Notes/Comments 477 2430 SVD03 Product/Service ID Qualifier HC, HP 2 Must be “HC” or “HP”. 479 2430 SVD05 Quantity - 15 Must be greater than zero. Must be less than or equal to “999,999.9”. Must be 0 or 1 decimal position. 479 2430 SVD06 Bundled Line Number - 6 Must be an integer (no decimals). 486 2430 DTP03 Line Check/Remit Date - 35 Must not be a future date. 10.4.18 Transaction Set Trailer The following table defines the specific details associated with Transaction Set Trailer. Note: A hyphen in the table below means N/A. Table 30. Transaction Set Trailer Page # Loop ID Reference Name Codes/Content Length Notes/Comments 496 - SE02 Transaction Set Control Number - 9 Must have the same value as ST02. Must be greater than zero. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 28 11 Appendices 11.1 Implementation Checklist In order to go live with CGS EDI, the following requirements must be met: • EDI Enrollment Form must be submitted or on file. • EDI Application • Approved Vendor Software or approved Clearinghouse or Billing Service • Approved Network Service Vendor Upon approval of the request to exchange files with CGS, a letter will be sent to the requestor. 11.2 Transmission Examples Figure 3. Example of the 837I Control Segments and Envelopes Please refer to the GPNet communications manual posted under Manuals and user guides (https://www.cgsmedicare.com/parta/edi/index.html). 11.3 Frequently Asked Questions Frequently asked questions can be accessed at: Medicare FFS EDI Operations (https://www.cms.gov/ElectronicBillingEDITrans/) CGS Frequently asked questions (https://www.cgsmedicare.com/). Click on the line of business, then the FAQ’s can be located on the menu. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 29 11.4 Acronym Listing Table 31. Acronyms Listing and Definitions Acronym Definition 276 276 Claim Status Request transaction 277 277 Claim Status Response transaction 277CA 277 Claim Acknowledgement 835 835 Electronic Remittance Advice transaction 837P 837 Professional Claims transaction 999 Implementation Acknowledgment ASC Accredited Standards Committee CAQH CORE Council for Affordable Quality Healthcare – Committee on Operating Rules for Information Exchange CEDI Common Electronic Data Interchange CG Companion Guide CMS Centers for Medicare & Medicaid Services CMN Certificate of Medical Necessity DME Durable Medical Equipment EDI Electronic Data Interchange ERA Electronic Remittance Advice FFS Medicare Fee-For-Service FISMA Federal Information Security Management Act GS/GE GS – Functional Group Header / GE – Functional Group Trailer HCPCS Healthcare Common Procedure Coding System HIPAA Health Insurance Portability and Accountability Act of 1996 HTTP Hyper Text Transfer Protocol HTTPS Hyper Text Transfer Protocol Secure IOM Internet-only Manual ISA/IEA ISA – Interchange Control Header / IEA – Interchange Control Trailer MAC Medicare Administrative Contractor MBI Medicare Beneficiary Identifier CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 30 Acronym Definition MIME Multipurpose Internet Mail Extensions NCPDP National Council for Prescription Drug Programs NPI National Provider Identifier NSV Network Service Vendor PDAC Pricing, Data Analysis and Coding PECOS Provider Enrollment Chain and Ownership System PHI Protected Health Information PID Packet Identifier sFTP Secure File Transfer Protocol SOAP Simple Object Access Protocol ST/SE ST – Transaction Set Header / SE – Transaction	837I_compguide.pdf
HP 2 Must be “HC” or “HP”. 479 2430 SVD05 Quantity - 15 Must be greater than zero. Must be less than or equal to “999,999.9”. Must be 0 or 1 decimal position. 479 2430 SVD06 Bundled Line Number - 6 Must be an integer (no decimals). 486 2430 DTP03 Line Check/Remit Date - 35 Must not be a future date. 10.4.18 Transaction Set Trailer The following table defines the specific details associated with Transaction Set Trailer. Note: A hyphen in the table below means N/A. Table 30. Transaction Set Trailer Page # Loop ID Reference Name Codes/Content Length Notes/Comments 496 - SE02 Transaction Set Control Number - 9 Must have the same value as ST02. Must be greater than zero. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 28 11 Appendices 11.1 Implementation Checklist In order to go live with CGS EDI, the following requirements must be met: • EDI Enrollment Form must be submitted or on file. • EDI Application • Approved Vendor Software or approved Clearinghouse or Billing Service • Approved Network Service Vendor Upon approval of the request to exchange files with CGS, a letter will be sent to the requestor. 11.2 Transmission Examples Figure 3. Example of the 837I Control Segments and Envelopes Please refer to the GPNet communications manual posted under Manuals and user guides (https://www.cgsmedicare.com/parta/edi/index.html). 11.3 Frequently Asked Questions Frequently asked questions can be accessed at: Medicare FFS EDI Operations (https://www.cms.gov/ElectronicBillingEDITrans/) CGS Frequently asked questions (https://www.cgsmedicare.com/). Click on the line of business, then the FAQ’s can be located on the menu. CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 29 11.4 Acronym Listing Table 31. Acronyms Listing and Definitions Acronym Definition 276 276 Claim Status Request transaction 277 277 Claim Status Response transaction 277CA 277 Claim Acknowledgement 835 835 Electronic Remittance Advice transaction 837P 837 Professional Claims transaction 999 Implementation Acknowledgment ASC Accredited Standards Committee CAQH CORE Council for Affordable Quality Healthcare – Committee on Operating Rules for Information Exchange CEDI Common Electronic Data Interchange CG Companion Guide CMS Centers for Medicare & Medicaid Services CMN Certificate of Medical Necessity DME Durable Medical Equipment EDI Electronic Data Interchange ERA Electronic Remittance Advice FFS Medicare Fee-For-Service FISMA Federal Information Security Management Act GS/GE GS – Functional Group Header / GE – Functional Group Trailer HCPCS Healthcare Common Procedure Coding System HIPAA Health Insurance Portability and Accountability Act of 1996 HTTP Hyper Text Transfer Protocol HTTPS Hyper Text Transfer Protocol Secure IOM Internet-only Manual ISA/IEA ISA – Interchange Control Header / IEA – Interchange Control Trailer MAC Medicare Administrative Contractor MBI Medicare Beneficiary Identifier CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 30 Acronym Definition MIME Multipurpose Internet Mail Extensions NCPDP National Council for Prescription Drug Programs NPI National Provider Identifier NSV Network Service Vendor PDAC Pricing, Data Analysis and Coding PECOS Provider Enrollment Chain and Ownership System PHI Protected Health Information PID Packet Identifier sFTP Secure File Transfer Protocol SOAP Simple Object Access Protocol ST/SE ST – Transaction Set Header / SE – Transaction Set Trailer TA1 Interchange Acknowledgment TR3 Technical Report Type 3 TRN Transaction Acknowledgment report (CEDI proprietary report) WSDL Web Services Description Language X12 A standards development organization that develops EDI standards and related documents for national and global markets. (See the official ASC X12 website.) X12N Insurance subcommittee of X12 CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 31 11.5 Change Summary The following table details the version history of this CG. Table 32. Companion Guide Version History Version Date Section(s) Changed Change Summary 1.0 November 5, 2010 All Initial Draft 2.0 January 3, 2011 All 1st Publication Version 3.0 April 2011 6.0 2nd Publication Version 4.0 September 2015 All 3rd Publication Version 4.0 June 2016 All Updated CMS URLs 5.0 March 2017 2.2,4.1.3,4.3&4.4 Updated hyperlinks and connectivity information 5.1 November 2017 All Updated CGS and CMS URL 6.0 March 2019 All 4th Publication Version 6.1 June 2020 1.3 11.4 6.2 April 2021 10.3.10 2400 DTP03 Service Date Language updated. 7.0 July 2022 All 508 Compliance 8.0 June 2023 3.1, 10.2.1 and 10.4.6 10.2.1 and 10.4.2 – Added instruction for +4 postal code when not provided by USPS. 3.1 Corrected spelling of Implementation	837I_compguide.pdf
Health Care Claim 837 Companion Guide Version 1.5 Refers to the following Technical Report Type 3 Guides: • ASC X12N 837 Institutional (version 005010X223A2) • ASC X12N 837 Professional (version 005010X222A1) • ASC X12N 837 Dental (version 005010X224A2) © Blue Cross Blue Shield of Massachusetts, February 2024 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 2 Preface This is a companion guide to the ASC X12N Implementation guides that were adopted under the Health Insurance Portability and Accountability Act (HIPAA). This guide details the data content needed to electronically exchange with Blue Cross Blue Shield of Massachusetts (Blue Cross). Transmissions based on this guide, used with the X12N Technical Report Type 3 guides, are compliant with both X12 syntax and those guides. This guide adheres to the ASC X12N Implementation Guides adopted under HIPAA. This guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Technical Report Type 3 guides. The content in this guide will be revised and republished when Blue Cross Blue Shield of Massachusetts makes improvements and/or changes to any referenced product, process, or program. This documentation is the confidential and proprietary property of Blue Cross Blue Shield of Massachusetts. Any unauthorized use, reproduction, or transfer of the documentation is strictly prohibited. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 3 Table of Contents INTRODUCTION ................................................................................................................................6 WHAT IS HIPAA?..............................................................................................................................6 PURPOSE OF THE ASC X12N IMPLEMENTATION GUIDE............................................................................6 PURPOSE OF THE BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE ...............................8 HOW TO OBTAIN COPIES OF THESE GUIDES ............................................................................................8 INTENDED AUDIENCE..........................................................................................................................8 NPI INFORMATION .............................................................................................................................8 ESTABLISHING A TRADING PARTNER AGREEMENT WITH BLUE CROSS .........................................................9 ESTABLISHING CONNECTIVITY WITH BLUE CROSS ..................................................................... 10 CONTACTS ..................................................................................................................................... 10 SETTING UP YOUR CONNECTION ........................................................................................................ 10 CHECKLIST: BEFORE YOU CAN SUBMIT TRANSACTIONS .......................................................................... 10 NEHEN ........................................................................................................................................ 11 PASSWORD RESET PROTOCOL........................................................................................................... 11 Server accounts ........................................................................................................................ 12 For individual user IDs ............................................................................................................... 12 SECURITY ...................................................................................................................................... 12 MAINTENANCE ................................................................................................................................ 13 TESTING ......................................................................................................................................... 14 CLAIMS TESTING PROCESS OVERVIEW ................................................................................................ 14 BLUE CROSS PROVIDER SUPPORT .............................................................................................. 15 BLUE CROSS CLAIM SUBMISSION GUIDELINES ........................................................................... 16 AVAILABLE COMMUNICATION FOLDERS ................................................................................................ 16 FILE NAME EXTENSION (.837) ............................................................................................................ 16 THE USAGE INDICATOR (ISA15) MUST BE APPROPRIATE ........................................................................ 16 PROFESSIONAL/DENTAL AND INSTITUTIONAL ....................................................................................... 17 SPECIAL CHARACTERS IN CLAIMS DATA ............................................................................................... 17 DELIMITERS ................................................................................................................................... 17 DUPLICATE FILE TRANSACTIONS ........................................................................................................ 17 BLUE CROSS IDENTIFICATION NUMBER REQUIREMENTS ........................................................... 18 REPORTING .................................................................................................................................... 19 REPORT OVERVIEW ......................................................................................................................... 19 REPORT SAMPLES ........................................................................................................................... 21 TA1 (interchange acknowledgment)............................................................................................ 21 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 4 999 (functional acknowledgement) ............................................................................................. 21 277 (acknowledgement of receipt of claim submission) ................................................................ 21 PDF (Submitter Batch Report) .................................................................................................... 24 BLUE CROSS SPECIFIC CONDITIONAL DATA REQUIREMENTS ................................................... 25 PROFESSIONAL CLAIMS (837P) DATA REQUIREMENTS ........................................................................... 25 General .................................................................................................................................... 25 Control segments ...................................................................................................................... 25 Detail data ................................................................................................................................ 27 INSTITUTIONAL CLAIMS (837I) DATA REQUIREMENTS ............................................................................. 41 General .................................................................................................................................... 41 Control segments ...................................................................................................................... 41 Detail data ................................................................................................................................ 43 DENTAL CLAIMS (837D) DATA REQUIREMENTS .................................................................................... 52 General .................................................................................................................................... 52 Control segments ...................................................................................................................... 52 Detail data ................................................................................................................................ 54 SPECIAL BILLING INSTRUCTIONS ................................................................................................. 61 COVERAGE SECONDARY TO MEDICARE OR OTHER PAYERS .................................................................... 61 837 SUBSCRIBER CLAIMS VS. DEPENDENT CLAIMS UNIQUE IDENTIFICATION ............................................... 64 837 ATYPICAL PROVIDERS ................................................................................................................ 64 LOOP/SEGMENT USED BY ATYPICAL PROVIDERS SEGMENT NAME ............................................................. 64 FACILITY CODE REQUIREMENTS FOR 837P AND 837I CLAIMS FOR BLUE CROSS ......................................... 64 GENERAL INFORMATION ON SPECIAL BILLING INSTRUCTIONS................................................................... 65 837I type of bill (TOB) convention ............................................................................................... 65 837I, 837P & 837D Provider taxonomy codes.............................................................................. 66 837I Special billing Instructions for vent beds or complex rehab stays ........................................... 66 Ambulatory surgi-centers (ASC) & observation services ............................................................... 67 837P Community mental health centers (CMHC) use of procedure code modifiers ........................ 67 837P billing instructions for radiology services (professional and technical components) ................ 68 837P CAA Surprise Billing (Consolidate Appropriations Act) 2022 Federal Mandate ...................... 70 FREQUENCY CODES 5, 7, AND 8 GUIDELINES .............................................................................. 71 FREQUENCY CODE 5 (LATE CHARGES) INSTITUTIONAL 837I CLAIMS ......................................................... 71 FREQUENCY CODE 7 (RESUBMISSION) ................................................................................................ 73 FREQUENCY CODE 8 (FULL VOID) ....................................................................................................... 75 MASSACHUSETTS 837 CLAIMS FOR OUT-OF-STATE MEDICAID AGENCIES ................................ 76 REMITTANCE DATE ........................................................................................................................ 79 NON-SPECIFIC PROCEDURE CODES REQUIRE A NARRATIVE IN SERVICE DETAIL LOOP .......... 79 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 5 REVISION HISTORY ........................................................................................................................ 80 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 6 Introduction What is HIPAA? The Health Insurance Portability and Accountability Act - Administration Simplification (HIPAA- AS) requires that Blue Cross Blue Shield of Massachusetts, Medicare, and all other health insurance payers in the United States, comply with the electronic data interchange standards for health care as established by the Secretary of Health and Human Services. The ASC X12N Implementation Guide 837 version 5010 and the Addenda (A1) for Health Care Claims have been established as the standard for claims transactions compliance. Purpose of the ASC X12N implementation guide The ASC X12N Implementation Guide version 5010, Addenda (A1) for Health Care Claims (837), Health Care Claim Acknowledgement (277CA), and Health Care Claim Payment/Advice (835) have been established as the standard for claims transactions compliance. Although the ASC X12N Implementation Guide contains requirements for use of specific segments and data elements within the segments, the guide was written for use by all health benefit payers. There are separate transactions for Health Care Claims: Institutional (837I), Professional (837P), and Dental (837D). Loops Loop usage within ASC X12N transactions and their implementation guides can be confusing. Carefully read the loop requirements in terms of the context or location within the transaction. The usage designator of a loop’s beginning segment indicates the usage of the loop. If a loop is used, the first segment (initial segments) of that loop is required even if it is marked situational. If Then The usage of the first segment in a loop is marked required… • The loop must occur at least once, unless it is nested in a loop that is not being used. • A note on the required initial segment of a nested loop will indicate dependency on the higher level loop. The first segment is situational… • There will be a segment note addressing use of the loop. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 7 • Any required segments in loops beginning with a situational segment occur only when the loop is used. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 8 Purpose of the Blue Cross Blue Shield of Massachusetts Companion Guide This document is the Blue Cross Blue Shield of Massachusetts specific Companion Guide to the ASC X12N Implementation Guide. The goals of the Blue Cross Companion Guide are to describe: 1. How to become an EDI Trading Partner with Blue Cross Blue Shield of Massachusetts 2. How to set up, test, and maintain a Trading Partner relationship with Blue Cross Blue Shield of Massachusetts 3. When conditional data elements and segments must be used with Blue Cross Blue Shield of Massachusetts transactions 4. Codes and data elements that are not applicable to Blue Cross Blue Shield of Massachusetts transactions This Companion Guide supplements but does not contradict any requirements in the ASC X12N version 5010 Implementation Guide or the Addenda. How to obtain copies of these guides • The ASC X12N Implementation Guides adopted for use in HIPAA transactions are available for purchase at: wpc-edi.com/HIPAA • The Blue Cross Blue Shield of Massachusetts Companion Guide is available electronically on the Provider Central website at: bluecrossma.com/provider Intended audience The intended audiences for this document are: • An officer of the corporation • The provider’s billing office • The technical area responsible for submitting electronic claims transactions to Blue Cross Blue Shield of Massachusetts NPI information The most up-to-date National Provider Identifier (NPI) billing instructions are available on the Provider Central website at bluecrossma.com/provider. Log on and click on Office Resources 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 9 to find links to billing instructions by provider type. Establishing a trading partner agreement with Blue Cross You must set up a Trading Partner Agreement in order to take advantage of the transactions and communication services offered by Blue Cross Blue Shield of Massachusetts. To start, speak with our EDI specialists (see Contacts). We will send you our starter kit which includes: Form name: Distributed to: The Provider Trading Partner Agreement An Officer of the Corporation empowered to enter a contract on behalf of the Corporation. The Trading Partner Enrollment Form Your billing office and information technology area (they should collaborate to fill out the form). The Secure File Transfer Account Request Form Your information technology group and agents of your billing office. We require that two signed hard copies of the Provider Trading Partner Agreement be delivered to Blue Cross and Blue Shield of Massachusetts, Inc. and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. at: 25 Technology Drive Hingham, MA 02043 Mail Stop 03-02 Attention: Scott Howard Director, Provider Operations & EDI Services You may email both the Trading Partner Enrollment Form and Secure File Transfer Account Request Form to [email protected]. Please use “Enrollment and Security Forms” in the subject line of the email. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 10 Establishing connectivity with Blue Cross This section explains the process for establishing connectivity to transmit and receive electronic transactions with Blue Cross Blue Shield of Massachusetts. It is important to note the difference between using http and https when accessing the servers. Contacts Type of contact Area contact Telephone number Technical Blue Cross EDI Support Team – [email protected] 1-800-771-4097 option 2 Setting up your connection Providers will deliver and pick up files via Blue Cross’s Tumbleweed Secure File Transfer server: Blue Cross Tumbleweed Secure File Transfer Server DNS Test staging.sftp.bluecrossma.com Production sftp.bluecrossma.com The types of file transmissions include: • Submitting 837s • Retrieving 277Cas, 999s, TA1’s, Submitter Reports and 835s Checklist: Before you can submit transactions You must: • Contact the EDI Support team ([email protected]) • Complete and return the following authorization forms: 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 11 • Provider Trading Partner Agreement • Trading Partner Enrollment Form (which will include your submitter ID) • Secure File Transfer Account Request Form listing: o Your server (please include your primary and secondary contacts) o Your primary system administrator contact o Your secondary system administrator contact o Each individual business user requiring access When Blue Cross has processed these forms, you will receive: • Tumbleweed mailbox and supporting directory o Please note: Your organization’s SFTP folder will be created using your submitter id; for example, e:\company\tradingpartners\(submitter id). This folder path will be shared with your organization. • Tumbleweed user ID to connect your server to your Tumbleweed mailbox • Two individual user IDs for users listed in Section 4 of the Secure File Transfer Account Request Form. The two users will be able to manually view and access their organization’s mailboxes • If requested, additional individual user IDs for business area users NEHEN Providers using NEHEN should contact the NEHEN contractor (Trizetto NEHEN) directly at 1-800-556-2231. Password reset protocol The password for your Tumbleweed account will be system-generated. Passwords will need to be reset every 90 days for individual user accounts. For server accounts, the password has a one year expiration. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 12 Server accounts We email each registered user three notices that the password is about to expire (“registered users” are determined from the names and email addresses on the security form): 1. Ten days before expiration 2. Five days before expiration 3. On the day of expiration Once one registered user has visited the site to “reset password,” we will email each registered user the new password. The user must update their server to	MPC_092315-4N___837_Companion_Guide.pdf
Technology Drive Hingham, MA 02043 Mail Stop 03-02 Attention: Scott Howard Director, Provider Operations & EDI Services You may email both the Trading Partner Enrollment Form and Secure File Transfer Account Request Form to [email protected]. Please use “Enrollment and Security Forms” in the subject line of the email. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 10 Establishing connectivity with Blue Cross This section explains the process for establishing connectivity to transmit and receive electronic transactions with Blue Cross Blue Shield of Massachusetts. It is important to note the difference between using http and https when accessing the servers. Contacts Type of contact Area contact Telephone number Technical Blue Cross EDI Support Team – [email protected] 1-800-771-4097 option 2 Setting up your connection Providers will deliver and pick up files via Blue Cross’s Tumbleweed Secure File Transfer server: Blue Cross Tumbleweed Secure File Transfer Server DNS Test staging.sftp.bluecrossma.com Production sftp.bluecrossma.com The types of file transmissions include: • Submitting 837s • Retrieving 277Cas, 999s, TA1’s, Submitter Reports and 835s Checklist: Before you can submit transactions You must: • Contact the EDI Support team ([email protected]) • Complete and return the following authorization forms: 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 11 • Provider Trading Partner Agreement • Trading Partner Enrollment Form (which will include your submitter ID) • Secure File Transfer Account Request Form listing: o Your server (please include your primary and secondary contacts) o Your primary system administrator contact o Your secondary system administrator contact o Each individual business user requiring access When Blue Cross has processed these forms, you will receive: • Tumbleweed mailbox and supporting directory o Please note: Your organization’s SFTP folder will be created using your submitter id; for example, e:\company\tradingpartners\(submitter id). This folder path will be shared with your organization. • Tumbleweed user ID to connect your server to your Tumbleweed mailbox • Two individual user IDs for users listed in Section 4 of the Secure File Transfer Account Request Form. The two users will be able to manually view and access their organization’s mailboxes • If requested, additional individual user IDs for business area users NEHEN Providers using NEHEN should contact the NEHEN contractor (Trizetto NEHEN) directly at 1-800-556-2231. Password reset protocol The password for your Tumbleweed account will be system-generated. Passwords will need to be reset every 90 days for individual user accounts. For server accounts, the password has a one year expiration. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 12 Server accounts We email each registered user three notices that the password is about to expire (“registered users” are determined from the names and email addresses on the security form): 1. Ten days before expiration 2. Five days before expiration 3. On the day of expiration Once one registered user has visited the site to “reset password,” we will email each registered user the new password. The user must update their server to use the new password. For individual user IDs The Tumbleweed application will display an error message (“login invalid”), indicating that the password has expired after 90 or 365 days. Users must contact the EDI Production Support team at [email protected] to have the password reset. The manage your password function can be used to: • Reset a password before the 90 or 365-day expiration • Obtain a new password if a password has been forgotten Security Blue Cross Blue Shield of Massachusetts is dedicated to maintaining the confidentiality of personal health information (PHI) and safeguarding member information as if it were our own. Associates are required to protect member privacy by using reasonable measures during all phases of the information-handling process: from collection and storage, to disclosure and disposal. This policy applies to the PHI of all applicants and past or present members. Information may be in the form of data in storage or in transit, on paper or in electronic format. Due to its sensitivity, the use and disclosure of PHI is restricted, except in circumstances where permitted or required by law or where appropriately authorized. Access to PHI is limited to those with a business need to know the information for treatment, payment, or health care operations, or as otherwise permitted or required by law. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 13 Maintenance Blue Cross allows transmission of 837 claim files 24 hours a day, seven days a week. For unscheduled maintenance (system abnormalities, outages), users will be notified via the contact information supplied on the Secure FTP Account Request Form. To avoid possible claim errors, please do not submit any files to Blue Cross during these periods. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 14 Testing Prior to submission to the product environment, Blue Cross requires testing for all sites submitting HIPAA claim submissions for the first time, as well as any claims processing changes related to Blue Cross Specific Data Elements. To help you achieve a successful test, please follow the appropriate format specifications (listed in this guide) and submission directions. To receive approval to move from test to production, you must receive a minimum “correct rate” of 95% for the test file submitted. Testing is an iterative process; Blue Cross will accept only one submission for each iteration of testing. Claims testing process overview Testing consists of the following stages: 1. File submission Coordinate with a Blue Cross EDI Support representative (see the Contacts section of this guide). For testing, we are not able to process a normal day of your production. However, the claims in your test file should simulate claims from normal business. Submit your test file to Blue Cross’s Tumbleweed Secure File Transfer test server. A Blue Cross EDI Support analyst reviews the file for HIPAA compliance and Blue Cross segment requirements. 2. Test results A Blue Cross EDI Support analyst will contact you by phone with results of your most recent test. Additionally, you must retrieve your reports from the test Blue Cross Tumbleweed Secure File Transfer server. Note: Stages 1 and 2 will repeat until you achieve a minimum 95% “correct rate” for the most recent file submitted. 3. Approval When your latest test iteration has achieved the “correct rate,” production move approval will be sent to the primary contact email address listed on your Trading Partner Enrollment Form. You may then submit and retrieve your files from the production Tumbleweed Secure File Transfer server. Testing support is available Monday through Friday, 8:30 a.m. to 3:30 p.m. ET. Refer to the Contacts section for help. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 15 Blue Cross provider support If you cannot find the answers to your questions in this guide, please use the contact information below to reach the appropriate support area in Blue Cross. 1. Blue Cross EDI support For technical questions or help related to any transactions, acknowledgments, or reports related to your health care claim submissions, please contact Blue Cross EDI Support. Phone: 1-800-771-4097 (option 2) Email: [email protected] 2. Provider Central website Provider Central provides information on our products, policies, and procedures, as well as FAQs and companion guides for various electronic transactions. Please refer to online documentation for the most current materials. Website: bluecrossma.com/provider 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 16 Blue Cross claim submission guidelines Claim files submitted for testing/production must meet the guidelines listed below. Available communication folders For each submitter ID that you can access, your security will allow you permission to two folders: inbound and outbound. Use the inbound folder to submit your ANSI 837 claim files and the outbound folder to retrieve the ANSI acknowledgement files and submitter report for each submitted ANSI 837 file. File name extension (.837) Claim files submitted to the inbound folder must have an extension of .837. You may continue to use your conventions and multiple nodes for the file name, but we can only process files from the inbound folder if its extension is .837. The usage indicator (ISA15) must be appropriate The usage indicator in the Interchange Control Header (ISA15) must be appropriate for the claim submission environment. Submissions for Must have ISA15 as Testing T Production P The result of an inappropriate usage indicator is reported only in an ANSI TA1 report. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 17 Professional/Dental and Institutional Test claim files Should contain a minimum of 25 claims and not exceed 50 claims in any one transaction set (batch). For testing, we are not able to process a normal day of your production. However, the claims in your test file should simulate claims associated with your normal business. Production claim files Must not exceed 4,999 claims in any one transmission. You may send multiple transmissions per day but each must not exceed 4,999 claims. Special characters in claims data Avoid the use of special characters in the claim data itself. Punctuation—comma (,), period (.), colon (:), semicolon (;), and hyphen (-)—should be avoided in the claims data (e.g. names, addresses, identifiers). Delimiters Delimiters are characters used to separate data and component elements or to terminate a segment. The following delimiters should be used when submitting an 837 claim file: Character Name * Asterisk data element separator ^ Carat repetition separator : Colon component element separator ~ Tilde segment terminator Duplicate file transactions Blue Cross will not process an 837 transaction submitted with duplicate ISA13 control numbers. Please submit all transactions with unique ISA13 control numbers that have not been submitted to Blue Cross in previous transactions. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 18 Blue Cross identification number requirements Alpha Numeric/alphanumeric Massachusetts Blue Cross Three letter alpha prefix Nine (without prefix) numeric or twelve (with prefix) alphanumeric characters Out-of-state Blue Cross Three letter alpha prefix Alphanumeric characters (typically 12-14) Federal Employee Plan (FEP) The letter R Eight numeric characters Note: Member IDs should not contain hyphens, spaces, or any special characters. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 19 Reporting This section describes the reports that are available to you from Blue Cross. The reports are stored for up to fourteen days for retrieval. Report overview Blue Cross generates the following list of reports. The quick reference table is followed by a description and sample of each report. For questions about any of the reports, use the Contacts section of this guide. Report name About the report TA1 BCBSMA.<submitter ID>. InterchangeAck.<datetime>.TA1 The TA1 or Interchange Acknowledgment is a reply to an interchange or transmission that has been sent. The TA1 verifies the envelopes only. This report notifies you of problems that were encountered in the interchange control structure. It acknowledges that we have received or rejected an entire transmission. 999 BCBSMA.<submitter ID>. FunctionalAck.<datetime>.999 The 999 or Functional Acknowledgment is a reply to the functional groups that are in any one interchange or transmission. It notifies you of our ability or inability to process the entire transaction based on ASC X12 syntax and structure rules. 277CA BCBSMA.<submitter ID>. ClaimAck.<datetime>.277 Our front-end includes Business and HIPAA rules to pre- process your claims. We send the 277 (often referred to as the Unsolicited 277) to notify you of transactions that are accepted for adjudication, as well as those that are not accepted. Claims failing our front-end editing process are not forwarded to the claims adjudication system. Claims passing the front-end editing process are forwarded to the claims adjudication system. PDF BCBSMA.<submitter ID>. In addition to the ANSI transactions available to you, we prepare a user-friendly Submitter Batch Report in Adobe PDF format. There are two sections – a summary 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 20 SubmitterReport.<datetime>.PDF and a detail. Totals are presented in the summary for each	MPC_092315-4N___837_Companion_Guide.pdf
claims data Avoid the use of special characters in the claim data itself. Punctuation—comma (,), period (.), colon (:), semicolon (;), and hyphen (-)—should be avoided in the claims data (e.g. names, addresses, identifiers). Delimiters Delimiters are characters used to separate data and component elements or to terminate a segment. The following delimiters should be used when submitting an 837 claim file: Character Name * Asterisk data element separator ^ Carat repetition separator : Colon component element separator ~ Tilde segment terminator Duplicate file transactions Blue Cross will not process an 837 transaction submitted with duplicate ISA13 control numbers. Please submit all transactions with unique ISA13 control numbers that have not been submitted to Blue Cross in previous transactions. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 18 Blue Cross identification number requirements Alpha Numeric/alphanumeric Massachusetts Blue Cross Three letter alpha prefix Nine (without prefix) numeric or twelve (with prefix) alphanumeric characters Out-of-state Blue Cross Three letter alpha prefix Alphanumeric characters (typically 12-14) Federal Employee Plan (FEP) The letter R Eight numeric characters Note: Member IDs should not contain hyphens, spaces, or any special characters. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 19 Reporting This section describes the reports that are available to you from Blue Cross. The reports are stored for up to fourteen days for retrieval. Report overview Blue Cross generates the following list of reports. The quick reference table is followed by a description and sample of each report. For questions about any of the reports, use the Contacts section of this guide. Report name About the report TA1 BCBSMA.<submitter ID>. InterchangeAck.<datetime>.TA1 The TA1 or Interchange Acknowledgment is a reply to an interchange or transmission that has been sent. The TA1 verifies the envelopes only. This report notifies you of problems that were encountered in the interchange control structure. It acknowledges that we have received or rejected an entire transmission. 999 BCBSMA.<submitter ID>. FunctionalAck.<datetime>.999 The 999 or Functional Acknowledgment is a reply to the functional groups that are in any one interchange or transmission. It notifies you of our ability or inability to process the entire transaction based on ASC X12 syntax and structure rules. 277CA BCBSMA.<submitter ID>. ClaimAck.<datetime>.277 Our front-end includes Business and HIPAA rules to pre- process your claims. We send the 277 (often referred to as the Unsolicited 277) to notify you of transactions that are accepted for adjudication, as well as those that are not accepted. Claims failing our front-end editing process are not forwarded to the claims adjudication system. Claims passing the front-end editing process are forwarded to the claims adjudication system. PDF BCBSMA.<submitter ID>. In addition to the ANSI transactions available to you, we prepare a user-friendly Submitter Batch Report in Adobe PDF format. There are two sections – a summary 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 20 SubmitterReport.<datetime>.PDF and a detail. Totals are presented in the summary for each transmission. Information about each claim is available in the detail section. 835 BCBSMA.<Submitter ID>. ClaimPayment.<datetime>.835 If you have elected to receive your remittance advices electronically, this transaction will be sent to your mailbox once claims have been adjudicated. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 21 Report samples Below are samples of each of the claim submission reports. The generic name in parentheses appears after the report name. The report samples are random samples from different batches of claims. TA1 (interchange acknowledgment) The TA1 report acknowledges that we have received or rejected an entire transmission. The report is delivered to your mailbox in stream format. For illustration purposes only, the report has been reformatted to show the individual segments. ISA00 00 ZZ00200 ZZ<SUBMITTER ID>0806301550U005010000000690T>~ TA10001976600806300951A000~ IEA0000000069~ 999 (functional acknowledgement) The 999 indicates accepted and rejected transaction sets within an interchange. For illustration purposes only, the report has been reformatted to show the individual segments. ISA00* 00 ZZ00200 ZZ<SUBMITTER ID>0806301551U005010000000700T>~ GSFA00200SUBMITTERID20080630155135X005010X223~ ST9990001~ AK1HC197665~ AK2837000000001~ AK5A~ AK9A111~ SE80001~ GE135~ IEA1000000070~ 277 (acknowledgement of receipt of claim submission) 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 22 The 277 notifies you of transactions that have passed our front-end edits and will be forwarded to the adjudication system. Also included are transactions that have failed the front- end and will not be forwarded for adjudication. The report is delivered to your mailbox in stream format. For illustration purposes only, the report has been reformatted to show the individual segments. ISA00* 00 ZZ00200 ZZSUBMITTER ID0806301551^005010000000350T>~ GSHN00200CU0120080630155135X005010X214~ ST2770001005010X214~ BHT00850839403.120080630155036TH~ HL1*201~ NM1PR2MA BLUE SHIELD***4600200~ TRN139403~ DTP050D820080630~ DTP009D820080630~ HL21211~ NM1412SUBMITTER NAME***46SUBMITTERID~ TRN2155E37~ STCA1>19>>6520080630WQ793~ QTY904~ QTYAA2~ AMTYU578~ AMTYY215~ HL32191~ NM1852PROVIDER NAME***XXNPI~ TRN12~ REFEI042888373~ 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 23 QTYQA1~ QTYQC2~ AMTYU207~ AMTYY215~ HL43PT~ NM1QC1LASTNAMEFIRSTNAME**MISUBSCRIBERID~ TRN26608108431353~ STCA1>19>>6520080630WQ207~ REFD923081081511500~ HL54PT~ NM1QC1LASTNAMEFIRSTNAME**MISUBSCRIBERID~ TRN26608112681460~ STCA7>486>>6520080630U81*******H51000 The Procedure Code 'ADMIN' is not a valid CPT or HCPCS Code for this Date of Service.~ REFD943081124916400~ HL64PT~ NM1QC1LASTNAMEFIRSTNAME***MISUBSCRIBERID~ TRN26608108431346~ STCA7>400>>6520080630U134*******H30011 The Sum of the SV1-02 elements is not equal to CLM-02 in the 2300 loop.~ REFD943081081694500~ SE390001~ GE135~ IEA1*000000035~ 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 24 PDF (Submitter Batch Report) The PDF—Submitter Batch Report—is not a technical ANSI transaction. It is delivered to your mailbox as a PDF so that you may have a visual report. The first section is a summary report for the transmission. The second section provides details for each claim for each provider. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 25 Blue Cross specific conditional data requirements Professional claims (837P) data requirements General This section will clarify when conditional data elements and segments must be used for Blue Cross professional claim transactions and will help you complete the 837P transaction. If you follow these guidelines, we'll be able to process your claims more accurately and efficiently. Control segments 837P implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions ISA - INTERCHANGE CONTROL HEADER ISA Interchange control header To start and identify an interchange of zero or more functional groups and interchange-related control segments ISA01 / I01 Authorizatio n information qualifier Required Use:  00 (no authorization information present/no meaningful information in I02) ISA02 / I02 Authorizatio n information Required Use:  10 spaces ISA03 / I03 Security information qualifier Required Use:  00 (no security information present / no meaningful 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 26 837P implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions information in I04) ISA04 / I04 Security information Required Use:  10 spaces ISA05 / I05 Interchange ID qualifier Required, qualifies the sender in ISA06 Use:  ZZ (mutually defined) ISA06 / I06 Interchange sender ID Required Use:  Your submitter ID (the same code used in GS02 and loop 1000A NM109) ISA07 / I07 Interchange ID Qualifier Required, qualifies the receiver in ISA08 Use:  ZZ (mutually defined) ISA08 / I08 Interchange Receiver ID Required Use:  00200 (BCBSMA) GS - FUNCTIONAL GROUP HEADER GS Functional Group Header To indicate the beginning of a functional group and to provide control information 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 27 837P implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions GS02 / 142 Application Sender Code Required Use:  Your submitter ID (the same code used in ISA06 and loop 1000A NM109) GS03 / 124 Application Receiver Code Required Use:  00200 (BCBSMA) GS08 / 480 Version / Release / Industry ID Code Required Use:  005010X222A1 (Professional Implementation Guide plus Addenda) Detail data 837P implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions Loop 1000A Submitter Name 020 NM1 Submitter name To supply the full name of an individual or organizational entity 020 NM109 / 67 Identification code Required Use your submitter ID (the same code used in ISA06 and GS02) 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 28 837P implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions Loop 1000B Receiver Name 020 NM1 Receiver name To supply the full name of an individual or organizational entity 020 NM109 / 67 Identification code Required Use:  00200 (BCBSMA) Loop 2000A Billing/Pay to Provider Hierarchical Level 003 PRV Billing / pay- to provider specialty information To specify the identifying characteristics of a provider 003 PRV02 / 128 Reference identification qualifier Required when taxonomy code is submitted in PRV03 Use:  ZZ (health care provider taxonomy code list) 003 PRV03 / 127 Reference identification Required when adjudication is known to be impacted by the provider taxonomy code In general, provider taxonomy code is not required for Blue Cross claims. However, if you have been instructed by Blue Cross to submit your provider taxonomy code in order to crosswalk your NPI, it is required. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 29 837P implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions Loop 2010AA Billing Provider Name 015 NM1 Billing provider name To supply the NPI 015 NM108 / 66 Identification code qualifier Required Use:  XX (NPI) 015 NM109 / 67 Identification code Required Use:  The billing provider’s 10-digit NPI Loop 2010AA Billing Provider Secondary Identification 035 REF Reference identification To identify the tax ID (1099 number) of the billing provider 035 REF01 / 128 Reference identification qualifier Required, used to provide the tax ID number of the billing provider Use:  EI (EIN number) OR  SY (SSN number) 035 REF02 / 127 Reference identification Required, used to provide the tax ID number of the billing provider Use the billing provider’s 9-digit tax ID number (without dashes) Loop 2000B Subscriber Information 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 30 837P implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions 005 SBR Subscriber information To record information specific to the primary insured and the insurance carrier for that insured 005 SBR02 / 1069 Individual relationship code Situational, but required if the subscriber is the patient Use:  18 (self) if the subscriber is the patient Important Note: Use this code only when the subscriber is the same person as the patient. If the subscriber is not the same person as the patient, do not use this element. Loop 2010BA Subscriber Name 015 NM1 Individual or organizationa l name To supply the full name of an individual or organizational entity 015 NM109 / 67 Identification code Situational, but required if the subscriber is the patient Use the patient’s identification number that was in effect on the date of service, exactly as it appears on the BCBS ID card. You must include the appropriate alpha prefix. Note: We do not issue unique identification numbers to all individual 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 31 837P implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions members. When submitting claims for a dependent, submit the 2010CA loop and the dependent’s demographic segments, along with the data for the actual subscriber of the policy in loop 2010BA. Loop 2010BB Payer Name 015 NM1 Individual or organization name Information about the Payer 015 NM108 Identification code qualifier Required Use:  PI (Payer) 015 NM109 Identification code Required Use:  00200 (BCBSMA) Loop 2300 Claim Information 130 CLM Health claim Use	MPC_092315-4N___837_Companion_Guide.pdf
is known to be impacted by the provider taxonomy code In general, provider taxonomy code is not required for Blue Cross claims. However, if you have been instructed by Blue Cross to submit your provider taxonomy code in order to crosswalk your NPI, it is required. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 29 837P implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions Loop 2010AA Billing Provider Name 015 NM1 Billing provider name To supply the NPI 015 NM108 / 66 Identification code qualifier Required Use:  XX (NPI) 015 NM109 / 67 Identification code Required Use:  The billing provider’s 10-digit NPI Loop 2010AA Billing Provider Secondary Identification 035 REF Reference identification To identify the tax ID (1099 number) of the billing provider 035 REF01 / 128 Reference identification qualifier Required, used to provide the tax ID number of the billing provider Use:  EI (EIN number) OR  SY (SSN number) 035 REF02 / 127 Reference identification Required, used to provide the tax ID number of the billing provider Use the billing provider’s 9-digit tax ID number (without dashes) Loop 2000B Subscriber Information 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 30 837P implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions 005 SBR Subscriber information To record information specific to the primary insured and the insurance carrier for that insured 005 SBR02 / 1069 Individual relationship code Situational, but required if the subscriber is the patient Use:  18 (self) if the subscriber is the patient Important Note: Use this code only when the subscriber is the same person as the patient. If the subscriber is not the same person as the patient, do not use this element. Loop 2010BA Subscriber Name 015 NM1 Individual or organizationa l name To supply the full name of an individual or organizational entity 015 NM109 / 67 Identification code Situational, but required if the subscriber is the patient Use the patient’s identification number that was in effect on the date of service, exactly as it appears on the BCBS ID card. You must include the appropriate alpha prefix. Note: We do not issue unique identification numbers to all individual 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 31 837P implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions members. When submitting claims for a dependent, submit the 2010CA loop and the dependent’s demographic segments, along with the data for the actual subscriber of the policy in loop 2010BA. Loop 2010BB Payer Name 015 NM1 Individual or organization name Information about the Payer 015 NM108 Identification code qualifier Required Use:  PI (Payer) 015 NM109 Identification code Required Use:  00200 (BCBSMA) Loop 2300 Claim Information 130 CLM Health claim Use to identify an early intervention provider 130 CLM12 / 1366 Special program code Situational, but required if you have been instructed by Blue Cross to include the special program indicator to identify yourself as a contracted early Use:  01 if the service relates to early & periodic screening, diagnosis and treatment (EPSDT) or child health assessment program (CHAP) 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 32 837P implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions intervention provider Refer to Appendix C 837P Special Program Indicator Loop 2300 Date of Accident 135 DTP Date, time, or period To specify any or all of a date, a time, or a time period related to an accident 135 DTP01 / 374 Date/time qualifier Situational, but required if CLM11-1, CLM11-2, or CLM11-3 = AA (auto accident), AP (another party responsible), EM (employment) or OA (other accident) Use:  439 if the service involves an accident 135 DTP02 / 1250 Reference identification Situational, but required if CLM11-1, CLM11-2, or CLM11-3 = AA (auto accident), AP (another party responsible), EM (employment) or OA (other accident) Use:  D8 (date expressed in format CCYYMMDD OR  DT (date and time expressed in format CCYYMMDDHHMM) 135 DTP03 – 1251 Date time period Situational, but required if CLM11-1, If you have indicated an injury diagnosis code, the date of the 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 33 837P implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions CLM11-2, or CLM11-3 = AA (auto accident), AP (another party responsible), EM (employment) or OA (other accident) injury or accident is required Loop 2310B Rendering Provider Name 250 NM1 Rendering provider name To supply the NPI 250 NM108 / 66 Identification code qualifier Required Use:  XX (NPI) 250 NM109 / 67 Identification code Required, used to provide the NPI of the rendering provider Use the rendering provider’s 10- digit NPI 255 PRV02 / 128 Reference identification qualifier Required when taxonomy code is submitted in PRV03 Use:  ZZ (health care provider taxonomy code list) 255 PRV03 / 127 Reference identification Required when adjudication is known to be impacted by the provider taxonomy In general, provider taxonomy code is not required for Blue Cross claims. However, if you have been instructed by Blue Cross to submit your provider 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 34 837P implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions code taxonomy code in order to crosswalk your NPI, it is required. Refer to Appendix C837I & 837P Provider Taxonomy Codes Loop 2310D Service Facility Location 250 NM1 Service facility location Use to identify the facility where the services were rendered 250 NM101 / 98 Entity identifier code Situational, but required when the location of the health care service is different than that carried in the 2010AA (billing provider) or 2010AB (pay-to provider) loops. **If the NPI is not different than the NPI submitted in 2010AA do not send the NPI in this loop. Use: One of the following values:  77 (service location – use when other codes in this element do not apply)  FA (facility) Refer to Appendix B Facility Code Requirements for 837P claims for Blue Cross 250 NM102 / 1065 Reference identification Situational, but required when the Use: 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 35 837P implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions qualifier location of the health care service is different than that carried in the 2010AA (billing provider) or 2010AB (pay-to provider) loops  2 (non-person entity) Refer to Appendix B Facility Code Requirements for 837P claims for Blue Cross 250 NM103 / 1035 Reference identification qualifier Situational, but required when the location of the health care service is different than that carried in the 2010AA (billing provider) or 2010AB (pay-to provider) loops Use: The name of the service facility where the services were rendered Refer to Appendix B Facility Code Requirements for 837P claims for Blue Cross 250 NM108 / 66 Reference identification qualifier Situational, but required when the location of the health care service is different than that carried in the 2010AA (billing Provider) or 2010AB (pay-to provider) loops Required, if NPI is known Refer to Appendix B Facility Code Requirements for 837P claims for Blue Cross 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 36 837P implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions 250 NM109 / 67 Reference identification Situational, but required when the location of the health care service is different than that carried in the 2010AA (billing provider) or 2010AB (pay-to provider) loops Required, if NPI is known Refer to Appendix B Facility Code Requirements for 837P claims for Blue Cross 265 N3 Service facility location address Use to identify the address of the facility where the services were rendered 265 N301 / 166 Address information Required when reporting a service facility location in NM1 Use:  Address line 1 of the service facility location Refer to Appendix B Facility Code Requirements for 837P claims for Blue Cross 265 N302 / 166 Address information Required when reporting a service facility location in NM1 Use:  Address line 2 of the service facility location 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 37 837P implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions Refer to Appendix B Facility Code Requirements for 837P claims for Blue Cross 270 N4 Service facility location city/state/ZIP Use to identify the city, state, and ZIP Code of the facility where the services were rendered 270 N401 / 19 Address information Required when reporting a service facility location in NM1 Use:  City of the service facility location Refer to Appendix B Facility Code Requirements for 837P claims for Blue Cross 270 N402 / 156 Address information Required when reporting a service facility location in NM1 Use:  State of the service facility location Refer to Appendix B Facility Code Requirements for 837P claims for Blue Cross 270 N403 / 116 Address information Required when reporting a service Use:  ZIP code of the service facility 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 38 Loop 2400 Professional Service 370 SV1 Professional service To specify the claim service detail for a Health Care professional 370 SV101- 1 / 235 Product / service ID qualifier Required, code identifying the type / source of the Use the appropriate HCPCS J- code (HC) for applicable drugs or injections. If the J-code is a 837P implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions facility location in NM1 location Refer to Appendix B Facility Code Requirements for 837P claims for Blue Cross 271 REF Service facility location secondary identification Use if a secondary number is necessary to identify the facility where the services were rendered 271 REF01 / 128 Reference identification qualifier Not required Not required 271 REF02 / 127 Reference identification Not required Not required 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 39 Loop 2400 Professional Service 370 SV1 Professional service To specify the claim service detail for a Health Care professional descriptive number used in product / service ID generic code requiring further explanation, also report the national drug code (NDC) in the LIN segment of loop 2410. 370 SV101- 3 / 1339 Procedure modifier Required when a modifier clarifies / improves the reporting accuracy of the associated procedure code Blue Cross requires standard modifiers for technical components (TC), professional components (26), and community mental health centers (AF, AH, AJ, HA, HE, HH, HI, HO, HR, TD). In addition, use standard modifiers when other services require them. Refer to the CPT and HCPCS manuals for a complete listing of standard modifiers. Refer to Appendix C. 837P Community Mental Health Centers Use of Procedure Code Modifiers Loop 2410 Drug Identification 494 LIN Item identification The NDC number used to specify billing/reporting for drugs provided that may be part of the service(s) described in SV1 494 LIN02 / 235 Product / service ID qualifier Situational, but required if this loop Use N4 (national drug code in 5- 4-2 Format) if the J-code reported 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 40 Loop 2400 Professional Service 370 SV1 Professional service To specify the claim service detail for a Health Care professional is used in SV1 is a generic	MPC_092315-4N___837_Companion_Guide.pdf
state, and ZIP Code of the facility where the services were rendered 270 N401 / 19 Address information Required when reporting a service facility location in NM1 Use:  City of the service facility location Refer to Appendix B Facility Code Requirements for 837P claims for Blue Cross 270 N402 / 156 Address information Required when reporting a service facility location in NM1 Use:  State of the service facility location Refer to Appendix B Facility Code Requirements for 837P claims for Blue Cross 270 N403 / 116 Address information Required when reporting a service Use:  ZIP code of the service facility 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 38 Loop 2400 Professional Service 370 SV1 Professional service To specify the claim service detail for a Health Care professional 370 SV101- 1 / 235 Product / service ID qualifier Required, code identifying the type / source of the Use the appropriate HCPCS J- code (HC) for applicable drugs or injections. If the J-code is a 837P implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions facility location in NM1 location Refer to Appendix B Facility Code Requirements for 837P claims for Blue Cross 271 REF Service facility location secondary identification Use if a secondary number is necessary to identify the facility where the services were rendered 271 REF01 / 128 Reference identification qualifier Not required Not required 271 REF02 / 127 Reference identification Not required Not required 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 39 Loop 2400 Professional Service 370 SV1 Professional service To specify the claim service detail for a Health Care professional descriptive number used in product / service ID generic code requiring further explanation, also report the national drug code (NDC) in the LIN segment of loop 2410. 370 SV101- 3 / 1339 Procedure modifier Required when a modifier clarifies / improves the reporting accuracy of the associated procedure code Blue Cross requires standard modifiers for technical components (TC), professional components (26), and community mental health centers (AF, AH, AJ, HA, HE, HH, HI, HO, HR, TD). In addition, use standard modifiers when other services require them. Refer to the CPT and HCPCS manuals for a complete listing of standard modifiers. Refer to Appendix C. 837P Community Mental Health Centers Use of Procedure Code Modifiers Loop 2410 Drug Identification 494 LIN Item identification The NDC number used to specify billing/reporting for drugs provided that may be part of the service(s) described in SV1 494 LIN02 / 235 Product / service ID qualifier Situational, but required if this loop Use N4 (national drug code in 5- 4-2 Format) if the J-code reported 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 40 Loop 2400 Professional Service 370 SV1 Professional service To specify the claim service detail for a Health Care professional is used in SV1 is a generic code that requires further explanation. 494 LIN03 / 234 Product / service ID Situational, but required if the qualifier N4 is used Use:  The NDC number in 5-4-2 format Loop 2420A Rendering Provider Name 500 NM1 Individual or organizational name To supply the full name of an individual or organizational entity 500 NM108 / 66 Identification code qualifier Required if the rendering provider is different from the provider identified in 2310A Use:  XX (NPI) 500 NM109 / 67 Identification code Required if the rendering provider is different from the provider identified in 2310A Use the rendering provider’s 10- digit NPI Back to top 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 41 Institutional Claims (837I) data requirements General The purpose of this section is to clarify when conditional data elements and segments must be used for Blue Cross institutional claims transactions. The following information is designed to help you complete the 837I transaction. If you follow these guidelines, we'll be able to process your claims more accurately and efficiently. Control segments 837I implementation guide data Payer specific data Position Segment ID / data element number Description 837 Requirements Blue Cross Blue Shield of MA instructions ISA – Interchange Control Header ISA Interchange control header To start and identify an interchange of zero or more functional groups and interchange-related control segments ISA01 / I01 Authorization information qualifier Required Use:  00 (no authorization information present / no meaningful information in I02) ISA02 / I02 Authorization information Required Use:  10 Spaces ISA03 / I03 Security information qualifier Required Use:  00 (no security information present / no meaningful information in I04) 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 42 837I implementation guide data Payer specific data Position Segment ID / data element number Description 837 Requirements Blue Cross Blue Shield of MA instructions ISA04 / I04 Security information Required Use:  10 Spaces ISA05 / I05 Interchange ID qualifier Required, qualifies the sender in ISA06 Use:  ZZ (mutually defined). ISA06 / I06 Interchange sender ID Required Use:  Your submitter ID (the same code used in GS02 and loop 1000A NM109) ISA07 / I07 Interchange ID qualifier Required, qualifies the receiver in ISA08 Use:  ZZ (mutually defined) ISA08 / I08 Interchange receiver ID Required Use:  00200 (Blue Cross) GS – Functional Group Header GS Functional group header To indicate the beginning of a functional group and to provide control information GS02 / 142 Application sender code Required Use:  Your submitter ID (the same code used in ISA06 and loop 1000A NM109) GS03 / Application receiver Required Use: 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 43 837I implementation guide data Payer specific data Position Segment ID / data element number Description 837 Requirements Blue Cross Blue Shield of MA instructions 124 code  00200 (Blue Cross) GS08 / 480 Version / release / industry identifier code Required Use:  005010X223A2 (Institutional Implementation Guide plus Addenda) Detail data 837I implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions Loop 1000A Submitter Name 020 NM1 Submitter name To supply the full name of an individual or organizational entity 020 NM109 / 67 Identification code Required Use your submitter ID (the same code used in ISA06 and GS02) Loop 1000B Receiver Name 020 NM1 Receiver To supply the full name of an individual or organizational 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 44 837I implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions name entity 020 NM109 / 67 Identification code Required Use:  00200 (BCBSMA) Loop 2000A Billing / Pay-to-Provider Specialty Information 003 PRV Provider information To specify the identifying characteristics of a provider 003 PRV02 / 128 Reference identification qualifier Required when taxonomy code is submitted in PRV03 Use :  ZZ (health care provider taxonomy code list) 003 PRV03 / 127 Reference identification Required when adjudication is known to be impacted by the provider taxonomy code In general, provider taxonomy code is not required for Blue Cross claims. However, if you have been instructed by Blue Cross to submit your provider taxonomy code in order to crosswalk your NPI, it is required. Refer to Appendix C 837I & 837P Provider Taxonomy Codes Loop 2010AA Billing Provider Name 015 NM1 Individual or To specify the primary To supply the NPI 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 45 837I implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions organizational name identification of the billing provider. 015 NM108 / 66 Identification code qualifier Required Use:  XX (NPI) 015 NM109 / 67 Identification code Required Use:  The billing provider’s 10- digit NPI Loop 2010AA Billing Provider Secondary ID 035 REF Reference identification Use if a secondary number is necessary to identify the billing provider 035 REF01 / 128 Reference identification qualifier Required, used to provide the tax ID number of the billing provider Use:  EI (EIN number) or SY (SSN number) 035 REF02 / 127 Reference identification Required, used to provide the tax ID number of the billing provider Use:  The billing provider’s 9- digit tax ID number (without dashes) Loop 2000B Subscriber Information 005 SBR Subscriber information To record information specific to the primary insured and the insurance carrier for that insured 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 46 837I implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions 005 SBR02 / 1069 Individual relationship Code Situational, but required if the subscriber is the patient Use:  18 (self) if the subscriber is the patient Important Note: Use this code only when the subscriber is the same person as the patient. If the subscriber is not the same person as the patient, do not use this element. Loop 2010BA Subscriber Name 015 NM1 Individual or organization name To supply the full name of an individual or organizational entity 015 NM109 / 67 Identification code Situational, but required if the subscriber is the patient Use the patient’s identification number that was in effect on the date of service, exactly as it appears on the Blue Cross ID card. You must include the appropriate alpha prefix. Note: We do not issue unique identification numbers to all individual members. When submitting claims for a dependent, submit the 2010CA 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 47 837I implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions loop and the dependent’s demographic segments, along with the data for the actual subscriber of the policy in loop 2010BA. DETAIL DATA 837I implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions Loop 2010BC Payer Name 015 NM1 Individual or organizational name Information about the Payer 015 NM108 Identification code qualifier Required Use:  PI (payer identification) 015 NM109 Identification code Required Use:  00200 (BCBSMA) 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 48 837I implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions Loop 2010BC Payer Name 015 NM1 Individual or organizational name Information about the Payer Loop 2300 Claim Information 130 CLM Health claim To specify basic data about the claim 130 CLM05-1 / 1331 Facility code value Required Required. For acute care hospitals, Blue Cross will crosswalk your NPI using this field as a secondary qualifier to your NPI. Loop 2310A Attending Physician Name 250 NM1 Individual or organizational name Use if it is necessary to identify the attending provider 250 NM108 / 66 Identification code qualifier Required, if loop is submitted Use:  XX (NPI) 250 NM109 / 67 Identification code Required, if loop is submitted Use:  The attending physician’s 10- 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 49 837I implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions Loop 2010BC Payer Name 015 NM1 Individual or organizational name Information about the Payer digit NPI Loop 2310A Attending Physician Name 255 PRV Provider information To specify the identifying characteristics of an attending provider 003 PRV02 / 128 Reference identification qualifier Required when taxonomy code is submitted in PRV03 Use the code ZZ to indicate the health care provider taxonomy code list. 003 PRV03 / 127 Reference identification Required when adjudication is known to be impacted by the provider taxonomy code In general, provider taxonomy code is not required for Blue Cross claims. However,	MPC_092315-4N___837_Companion_Guide.pdf
the subscriber is the same person as the patient. If the subscriber is not the same person as the patient, do not use this element. Loop 2010BA Subscriber Name 015 NM1 Individual or organization name To supply the full name of an individual or organizational entity 015 NM109 / 67 Identification code Situational, but required if the subscriber is the patient Use the patient’s identification number that was in effect on the date of service, exactly as it appears on the Blue Cross ID card. You must include the appropriate alpha prefix. Note: We do not issue unique identification numbers to all individual members. When submitting claims for a dependent, submit the 2010CA 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 47 837I implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions loop and the dependent’s demographic segments, along with the data for the actual subscriber of the policy in loop 2010BA. DETAIL DATA 837I implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions Loop 2010BC Payer Name 015 NM1 Individual or organizational name Information about the Payer 015 NM108 Identification code qualifier Required Use:  PI (payer identification) 015 NM109 Identification code Required Use:  00200 (BCBSMA) 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 48 837I implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions Loop 2010BC Payer Name 015 NM1 Individual or organizational name Information about the Payer Loop 2300 Claim Information 130 CLM Health claim To specify basic data about the claim 130 CLM05-1 / 1331 Facility code value Required Required. For acute care hospitals, Blue Cross will crosswalk your NPI using this field as a secondary qualifier to your NPI. Loop 2310A Attending Physician Name 250 NM1 Individual or organizational name Use if it is necessary to identify the attending provider 250 NM108 / 66 Identification code qualifier Required, if loop is submitted Use:  XX (NPI) 250 NM109 / 67 Identification code Required, if loop is submitted Use:  The attending physician’s 10- 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 49 837I implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions Loop 2010BC Payer Name 015 NM1 Individual or organizational name Information about the Payer digit NPI Loop 2310A Attending Physician Name 255 PRV Provider information To specify the identifying characteristics of an attending provider 003 PRV02 / 128 Reference identification qualifier Required when taxonomy code is submitted in PRV03 Use the code ZZ to indicate the health care provider taxonomy code list. 003 PRV03 / 127 Reference identification Required when adjudication is known to be impacted by the provider taxonomy code In general, provider taxonomy code is not required for Blue Cross claims. However, if you have been instructed by Blue Cross to submit your provider taxonomy code in order to crosswalk your NPI, it is required. Refer to Appendix C 837I & 837P Provider Taxonomy Codes 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 50 Detail data 837I implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions Loop 2310B Operating Physician Secondary ID 271 REF Reference identification Use if a secondary number is necessary to identify the operating physician provider 271 REF01 / 128 Reference identification qualifier Not required Not required Loop 2310C Other Provider Secondary ID 271 REF Reference identification Use if a secondary number is necessary to identify the other provider 271 REF01 / 128 Reference identification qualifier Not required Not required Loop 2400 Institutional Service Line 375 SV2 INSTITUTIONAL SERVICE LINE To specify the claim service detail for a Health Care institution 375 SV201 / 234 Product/service ID Required Required. Blue Cross has issued special billing instructions when billing for vent beds or complex rehabilitation stays. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 51 837I implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions See Appendix C 837I Special Billing Instructions for Revenue Codes 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 52 Dental Claims (837D) Data Requirements General The purpose of this section is to clarify when conditional data elements and segments must be used for Blue Cross Blue Shield of Massachusetts dental claims transactions. The following information is designed to help you complete the 837D transaction. If you follow these guidelines, we'll be able to process your claims more accurately and efficiently. Control segments 837D implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions ISA – Interchange Control Header ISA Interchange control header To start and identify an interchange of zero or more functional groups and interchange-related control segments ISA01 / I01 Authorization information qualifier Required Use:  00 (no authorization information present / no meaningful information in I02) ISA02 / I02 Authorization information Required Enter:  10 spaces ISA03 / I03 Security information qualifier Required Use:  00 (no security information present / no meaningful 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 53 837D implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions information in I04) ISA04 / I04 Security information Required Enter:  10 spaces ISA05 / I05 Interchange ID qualifier Required, this ID qualifies the Sender in ISA06 Use:  ZZ (mutually defined) ISA06 / I06 Interchange sender ID Required Use:  Your submitter ID (the same code used in GS02 and loop 1000A NM109) ISA07 / I07 Interchange ID qualifier Required. This ID qualifies the receiver in ISA08 Use:  ZZ (mutually defined) ISA08 / I08 Interchange receiver ID Required Use:  00200 (BCBSMA) GS – Functional Group Header GS Functional group header To indicate the beginning of a functional group and to provide control information GS02 / 142 Application sender Required Use:  Your submitter ID (the same 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 54 837D implementation guide data Payer specific data Position Segment ID / data element number Description 837 requirements Blue Cross instructions code code as used in ISA06 and Loop 1000A NM109) GS03 / 124 Application receiver code Required Use:  00200 (BCBSMA) GS08 / 480 Version / release / industry identifier code Required Use:  005010X224A2~ (Dental Implementation Guide plus Addenda) Detail data 837D implementation guide data Payer specific data Position Segment ID / data element number Description 837 Requirements Blue Cross instructions Loop 1000A Submitter Name 020 NM1 Submitter name To supply the full name of an individual or organizational entity 020 NM109 / 67 Identification code Required Use:  Your submitter ID (the same code as used in ISA06 and 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 55 837D implementation guide data Payer specific data Position Segment ID / data element number Description 837 Requirements Blue Cross instructions GS02) Loop 1000B Receiver Name 020 NM1 Receiver name To supply the full name of an individual or organizational entity 020 NM109 / 67 Identification code Required Use:  00200 (BCBSMA) Loop 2000A Billing / Pay-to-Provider Specialty Information 003 PRV Provider information To specify the identifying characteristics of a provider 003 PRV02 / 128 Reference identification qualifier Required when taxonomy code is submitted in PRV03 Use:  The code ZZ to indicate the health care provider taxonomy code list. 003 PRV03 / 127 Reference identification Required when adjudication is known to be impacted by the provider taxonomy code In general, provider taxonomy code is not required for Blue Cross claims. However, if you have been instructed by Blue Cross to submit your provider taxonomy code in order to crosswalk your NPI, it is required. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 56 837D implementation guide data Payer specific data Position Segment ID / data element number Description 837 Requirements Blue Cross instructions Loop 2010AA Billing Provider Name 015 NM1 Individual or organizational name To supply the NPI 015 NM108 / 66 Identification code qualifier Required Use:  XX (NPI) 015 NM109 / 67 Identification code Required Use:  The billing provider’s 10-digit NPI Loop 2010AA Billing Provider Secondary Identification 035 REF Reference Identification Use to identify the Tax ID (1099 number) of the billing provider 035 REF01 / 128 Reference identification qualifier Required, used to provide the tax ID number of the billing provider Use:  EI (EIN Number) OR  SY (SSN number) 035 REF02 / 127 Reference identification Required, used to submit the tax ID number of the billing provider Use:  The billing provider’s 9-digit tax ID number (without dashes) Loop 2000B Subscriber Information 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 57 837D implementation guide data Payer specific data Position Segment ID / data element number Description 837 Requirements Blue Cross instructions 005 SBR Subscriber information To record information specific to the primary insured and the insurance carrier for that insured 005 SBR02 / 1069 Individual relationship code Situational, but required if the subscriber is the patient Use:  18 (Self) if the subscriber is the patient Important note: If the subscriber is not the patient, do not use this data element. Refer to the appropriate patient segments. Loop 2010BA Subscriber Name 015 NM1 Individual or organizational name To supply the full name of an individual or organizational entity 015 NM109 / 67 Identification code qualifier Situational, but required if the subscriber is the patient Use the patient’s identification number that was in effect on the date of service, exactly as it appears on the BCBS ID card. You must include the appropriate alpha prefix. Note: We do not issue unique identification numbers to all individual members. When submitting claims for a 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 58 837D implementation guide data Payer specific data Position Segment ID / data element number Description 837 Requirements Blue Cross instructions dependent, submit the 2010CA loop and the dependent’s demographic segments, along with the data for the actual subscriber of the policy in loop 2010BA. Loop 2010BB Payer Name 015 NM1 Individual or organizational name Information about the payer 015 NM108 Identification code qualifier Required Use:  PI (payer identification) 015 NM109 Identification code Required Use:  00200 (BCBSMA) Loop 2300 Date of Accident 135 DTP Date or time or period To specify the date of an accident 135 DTP01 / 374 Date/time qualifier Situational, but required if CLM11-1, CLM11-2, or CLM11-3 = AA (auto accident), EM (employment) or OA (other accident) Use:  439 if the service involves an accident 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 59 837D implementation guide data Payer specific data Position Segment ID / data element number Description 837 Requirements Blue Cross instructions 135 DTP02 / 1250 Reference identification Situational, but required if CLM11-1, CLM11-2, or CLM11-3 = AA (auto accident), EM (employment) or OA (other accident) Use:  D8 (date expressed in format CCYYMMDD 135 DTP03 - 1251 Date time period Situational, but required if CLM11-1, CLM11-2, or CLM11-3 = AA (auto accident), EM (employment) or OA (other accident) If you have indicated a diagnosis code value greater than 80000 (injury), the date of the injury or accident is required. Loop 2300 Claim Note 190 NTE Note/special instruction To transmit information in a free-format, if necessary, for comment or special instruction 190 NTE01 / 363 Note reference code Situational, but required for reporting periodontal charting information Use:	MPC_092315-4N___837_Companion_Guide.pdf
number of the billing provider Use:  The billing provider’s 9-digit tax ID number (without dashes) Loop 2000B Subscriber Information 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 57 837D implementation guide data Payer specific data Position Segment ID / data element number Description 837 Requirements Blue Cross instructions 005 SBR Subscriber information To record information specific to the primary insured and the insurance carrier for that insured 005 SBR02 / 1069 Individual relationship code Situational, but required if the subscriber is the patient Use:  18 (Self) if the subscriber is the patient Important note: If the subscriber is not the patient, do not use this data element. Refer to the appropriate patient segments. Loop 2010BA Subscriber Name 015 NM1 Individual or organizational name To supply the full name of an individual or organizational entity 015 NM109 / 67 Identification code qualifier Situational, but required if the subscriber is the patient Use the patient’s identification number that was in effect on the date of service, exactly as it appears on the BCBS ID card. You must include the appropriate alpha prefix. Note: We do not issue unique identification numbers to all individual members. When submitting claims for a 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 58 837D implementation guide data Payer specific data Position Segment ID / data element number Description 837 Requirements Blue Cross instructions dependent, submit the 2010CA loop and the dependent’s demographic segments, along with the data for the actual subscriber of the policy in loop 2010BA. Loop 2010BB Payer Name 015 NM1 Individual or organizational name Information about the payer 015 NM108 Identification code qualifier Required Use:  PI (payer identification) 015 NM109 Identification code Required Use:  00200 (BCBSMA) Loop 2300 Date of Accident 135 DTP Date or time or period To specify the date of an accident 135 DTP01 / 374 Date/time qualifier Situational, but required if CLM11-1, CLM11-2, or CLM11-3 = AA (auto accident), EM (employment) or OA (other accident) Use:  439 if the service involves an accident 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 59 837D implementation guide data Payer specific data Position Segment ID / data element number Description 837 Requirements Blue Cross instructions 135 DTP02 / 1250 Reference identification Situational, but required if CLM11-1, CLM11-2, or CLM11-3 = AA (auto accident), EM (employment) or OA (other accident) Use:  D8 (date expressed in format CCYYMMDD 135 DTP03 - 1251 Date time period Situational, but required if CLM11-1, CLM11-2, or CLM11-3 = AA (auto accident), EM (employment) or OA (other accident) If you have indicated a diagnosis code value greater than 80000 (injury), the date of the injury or accident is required. Loop 2300 Claim Note 190 NTE Note/special instruction To transmit information in a free-format, if necessary, for comment or special instruction 190 NTE01 / 363 Note reference code Situational, but required for reporting periodontal charting information Use:  ADD (Additional Information) Blue Cross requires this segment for periodontal services in order to report the periodontal case type 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 60 837D implementation guide data Payer specific data Position Segment ID / data element number Description 837 Requirements Blue Cross instructions 190 NTE02 / 352 Description Situational, but required for reporting periodontal charting information Required when billing for the following periodontal procedures: D4341 and D4910 Use the following values to report periodontal case types:  PERI1: Case type I - gingival disease  PERI2: Case type II - early periodontitis  PERI3: Case type III - moderate periodontitis  PERI4: Case type IV - advanced periodontitis Loop 2310B Rendering Provider Name 250 NM1 Rendering provider name To supply the NPI 250 NM108 / 66 Identification code qualifier Required Use:  XX (NPI) 250 NM109 / 67 Identification code Required, used to provide the NPI of the rendering/treating provider Use the rendering provider’s 10- digit NPI 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 61 837D implementation guide data Payer specific data Position Segment ID / data element number Description 837 Requirements Blue Cross instructions 255 PRV02 / 128 Reference identification qualifier Required when taxonomy code is submitted in PRV03 Use:  ZZ (health care provider taxonomy code list) 255 PRV03 / 127 Reference identification Required when adjudication is known to be impacted by the provider taxonomy code In general, provider taxonomy code is not required for Blue Cross claims. However, if you have been instructed by Blue Cross to submit your provider taxonomy code in order to crosswalk your NPI, it is required. Refer to Appendix C 837I & 837P Provider Taxonomy Codes Special BILLING Instructions Coverage secondary to Medicare or other payers If the 837 claim transaction reports that Blue Cross Blue Cross Blue Shield Massachusetts is the secondary payer to Medicare or another payer (Coordination of Benefits information), review the following to ensure the data is populated correctly. Refer to the appropriate 837 Technical Type 3 Report Guide for further clarification. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 62 Blue Cross realizes that the depth of Coordination of Benefits information returned to you in the Primary Payer’s remittance may be less than ideal, but we ask you to work with these payers so that we may properly adjudicate your claim. The following information is required by Blue Cross: • SBR01 = “S” in Loop 2000B if BCBSMA is the Secondary Payer • SBR01 = “P” in Loop 2320 for Primary Carrier Payment information • CAS segment(s) in Loop 2320 required on Inpatient Institutional Claims • AMT segments within Loop 2320 required on all Secondary Claims • SVD02 element in Loop 2430 required for all 837 Professional, Dental and Outpatient Institutional Claims • CAS segment(s) in Loop 2430 required for all 837 Professional, Dental, and Outpatient Institutional Claims In addition to the data outlined above, providers should also verify that Loop 2330A (Other Subscriber Name) and Loop 2330B (Other Payer Name) are populated with all the required information for the various segments included within these loops. When submitting claims where Medicare is the Primary Payer, BCBSMA requires that SBR09 equals “MA” (Medicare Part A) or “MB” (Medicare Part B) within Loop 2320 (Other Subscriber Information). Loop 2000B (SBR01 = S) Loop 2320 (SBR01 = P) Example: SBRP01*MB*MB~ Item 837D 837I 837PItem 837D 837I 837P Item 837D 837I 837P Claim level 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 63 Total charges Loop 2300 CLM02 Total paid amount Loop 2320 AMT02 (Where AMT01 = “D”) Total deductible amount N/A Loop 2320 \| CAS03 (where CAS01 = “PR” and CAS02 = “1”) N/A Total co- insurance amount* N/A Loop 2320 \| CAS03 (where CAS01 = “PR” and CAS02 = “2”) N/A Line level 837D 837I 837P Line charges Loop 2400 \| SV302 Loop 2400 \| SV203 OutPatient Loop 2400 \| SV102 Line payment 2430 SVD02 Line deductible amount* Loop 2430 \| CAS03 (where CAS01 = “PR” and CAS02 = “1”) Line co- insurance amount* Loop 2430 \| CAS03 (where CAS01 = “PR” and CAS02 = “2”) Note: If deductible amount and co-insurance amount are both available, do not present them in two CAS segments. Instead, use a single “Patient Responsibility” CAS segment. A members, 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 64 837 Subscriber claims vs. dependent claims unique identification Segments in the subscriber loop if the claim is for a dependent. You must submit a 2010BA loop with the actual subscriber of the Blue Cross policy for all claims submitted regardless of whether the services are for the subscriber or for a dependent. Because we do not issue unique identification numbers to all Blue Cross members, we require that the 2010BA loop (subscriber name) be used when submitting subscriber only claims along with the demographic segments for the subscriber of the policy. When submitting claims for a dependent of the subscriber, you must also submit the 2010CA loop along with the dependent demographic segments (do not submit the demographic segments in the subscriber loop if the claim is for a dependent). You must submit a 2010BA loop with the actual subscriber of the BCBS policy in loop 2010BA for all claims submitted to Blue Cross regardless of if the services are for the subscriber or the subscriber’s dependent (spouse, child, etc.). 837 Atypical providers The NM108 and NM109 elements within specific loops that refer to NPI enumeration will not be used because most atypical providers do not have an NPI. Instead, atypical providers should submit their Blue Cross Legacy provider number in element REF02 within the 2010BB loops. Please note that within those loops, element REF01 should equal “G2.” Instructions are also located in Section 6.1 and Section 6.2 within the 837P and 837I Loop Specific Data tables respectively. Loop/Segment used by atypical providers segment name 2010BB \| REF Billing provider secondary identification 2310B \| REF (Claim Level) Rendering provider secondary identification 2420A \| REF (Service Line Level) Rendering provider secondary identification Facility code requirements for 837P and 837I claims for Blue Cross The service facility location loop—2310C for Professional and 2310E for Institutional—is required when the location where the service was rendered is different than that carried in the 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 65 2010AA (billing provider) or 2010AB (pay-to provider) loops. The service facility location loop (2310E) supplies information of where care was delivered to our member. It is not required for services delivered in the patient’s home or for laboratory services. Blue Cross needs only the following data elements for claims adjudication: NM1FA2FACILITY NAME***XX1234567890~ <= NPI of service site in NM109. N3STREET ADDRESS~<= service site street address, using standard USPO codes. N4CITYSTZIPCD~<= service city, state and zip code. Example: NM1FA2GENERAL HOSPITAL***XX1234567890~ N3123 ANY ST ~ N4ANYTOWNMA12345~ General Information on special billing instructions 837I type of bill (TOB) convention Blue Cross recognizes all NUBC approved type of bill values. However, most claims for our facility partners require only a limited set of these codes. To crosswalk to the acute care hospital Legacy provider identification, we use two significant digits from the TOB as a secondary qualifier to your NPI. This value is taken from your submission in the facility code value of your claim (2300 CLM05-1). For services provided in this area of the hospital Submit this value in the first position of TOB And submit this value in the second position of TOB Inpatient 1 1 Outpatient 1 3 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 66 For services provided in this area of the hospital Submit this value in the first position of TOB And submit this value in the second position of TOB Hospital-based community health center 7 9 Surgical day care 8 3 837I, 837P & 837D Provider taxonomy codes Blue Cross does not require taxonomy codes for most claims. However, in certain limited conditions, a taxonomy code is used as a secondary qualifier to your NPI in our crosswalk. Example: 2000A — BILLING PROVIDER HIERARCHICAL LEVEL PRV✽BI✽PXC✽207Q00000X~ 2310B — RENDERING PROVIDER NAME PRV✽PE✽PXC✽1223G0001X~ 837I Special billing Instructions for vent beds or complex rehab stays Blue Cross has issued special billing instructions for revenue code use when billing vent beds or complex rehabilitation stays. For services provided in this area of the hospital Please submit this revenue code SNF/Vent bed 0129 Complex rehab stays 0139 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 67 Ambulatory surgi-centers (ASC) & observation services When billing revenue codes for ASC or observation services, Blue Cross requires that the charge amount for the service must be greater than zero ($0). Additional information and the most up-to-date billing instructions are available on our Provider Central website at bluecrossma.com/provider. 837P Community mental	MPC_092315-4N___837_Companion_Guide.pdf
segment name 2010BB \| REF Billing provider secondary identification 2310B \| REF (Claim Level) Rendering provider secondary identification 2420A \| REF (Service Line Level) Rendering provider secondary identification Facility code requirements for 837P and 837I claims for Blue Cross The service facility location loop—2310C for Professional and 2310E for Institutional—is required when the location where the service was rendered is different than that carried in the 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 65 2010AA (billing provider) or 2010AB (pay-to provider) loops. The service facility location loop (2310E) supplies information of where care was delivered to our member. It is not required for services delivered in the patient’s home or for laboratory services. Blue Cross needs only the following data elements for claims adjudication: NM1FA2FACILITY NAME***XX1234567890~ <= NPI of service site in NM109. N3STREET ADDRESS~<= service site street address, using standard USPO codes. N4CITYSTZIPCD~<= service city, state and zip code. Example: NM1FA2GENERAL HOSPITAL***XX1234567890~ N3123 ANY ST ~ N4ANYTOWNMA12345~ General Information on special billing instructions 837I type of bill (TOB) convention Blue Cross recognizes all NUBC approved type of bill values. However, most claims for our facility partners require only a limited set of these codes. To crosswalk to the acute care hospital Legacy provider identification, we use two significant digits from the TOB as a secondary qualifier to your NPI. This value is taken from your submission in the facility code value of your claim (2300 CLM05-1). For services provided in this area of the hospital Submit this value in the first position of TOB And submit this value in the second position of TOB Inpatient 1 1 Outpatient 1 3 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 66 For services provided in this area of the hospital Submit this value in the first position of TOB And submit this value in the second position of TOB Hospital-based community health center 7 9 Surgical day care 8 3 837I, 837P & 837D Provider taxonomy codes Blue Cross does not require taxonomy codes for most claims. However, in certain limited conditions, a taxonomy code is used as a secondary qualifier to your NPI in our crosswalk. Example: 2000A — BILLING PROVIDER HIERARCHICAL LEVEL PRV✽BI✽PXC✽207Q00000X~ 2310B — RENDERING PROVIDER NAME PRV✽PE✽PXC✽1223G0001X~ 837I Special billing Instructions for vent beds or complex rehab stays Blue Cross has issued special billing instructions for revenue code use when billing vent beds or complex rehabilitation stays. For services provided in this area of the hospital Please submit this revenue code SNF/Vent bed 0129 Complex rehab stays 0139 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 67 Ambulatory surgi-centers (ASC) & observation services When billing revenue codes for ASC or observation services, Blue Cross requires that the charge amount for the service must be greater than zero ($0). Additional information and the most up-to-date billing instructions are available on our Provider Central website at bluecrossma.com/provider. 837P Community mental health centers (CMHC) use of procedure code modifiers Blue Cross requires that a CMHC submit a procedure code modifier specific to the specialty of the rendering staff provider on each line of the claim. Blue Cross requires that the billing NPI contracted for community mental health centers also be submitted in the rendering/servicing provider loop (2310B or 2420A). Values to enter in the modifier field Modifier Licensure level AF Psychiatrist AH Psychologist AJ Licensed independent clinical social worker HA Child psychiatrist HE Psychiatric nurse practitioner HH Licensed alcohol and drug counselors HI Applied behavioral analysis (ABA) therapist HO Licensed mental health counselor 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 68 HR Licensed marriage & family therapist TD Clinical nurse specialist 837P billing instructions for radiology services (professional and technical components) If you are a provider contracted to perform radiology services using the modifiers of 26 (professional) and TC (technical), please bill your claims using these guidelines. You may be contracted to render and bill technical services with your individual NPI or your billing NPI. When billing for On rendering provider line put NPI of the Modifier required Professional component Rendering provider 26 Technical component Provider contracted to render technical services TC Separate bills for professional and technical components For Instructions Modifier Professional component bill • Submit the NPI and the tax ID of the billing provider in the 2010AA loop. • Submit the NPI (and optionally, the tax ID) of the rendering provider in the 2310B loop. • If another provider within the group has rendered another service, submit the NPI of that service rendering provider in the 2420A loop. 26 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 69 For Instructions Modifier Technical component bill Note: to correctly adjudicate the technical component service, you must identify the provider that is contracted with Blue Cross to perform the technical service • Submit the NPI and the Tax ID of the billing provider in the 2010AA loop. • If the NPI of the billing provider is contracted with Blue Cross to perform the technical service, no other provider loops are required. Our ANSI translator is in accordance with the ANSI standard and will apply the billing provider to each technical service. If your software requires it, you may re-submit the NPI of the billing provider in the rendering (2310B) loop. • If the NPI of the billing provider is not contracted with Blue Cross to perform the technical service, submit the NPI (and optionally, the tax ID) of the provider contracted to perform the technical service in the rendering (2310B) loop. TC One bill for professional and technical components To correctly adjudicate the technical component service, you must use the NPI of the provider contracted with Blue Cross as the rendering provider NPI for the technical service. 1. Submit the NPI and the tax ID of the billing provider in the 2010AA loop. 2. The ANSI Standard allows you to submit the NPI of the rendering provider in the 2310B loop. The standard applies that NPI as the rendering provider to all services. Remember, the technical component service (modifier TC) will adjudicate correctly only if the rendering provider is contracted with Blue Cross to provide the technical service. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 70 Option Description Actions 1 Identify the contracted technical component provider in the 2310B loop • Submit the NPI (and, optionally, the tax ID) of the provider contracted with Blue Cross to perform the technical service in the rendering (2310B) loop. • For each service other than the technical component service, submit the NPI of the rendering provider in the service rendering (2420A) loop. 2 Identify the professional component provider in the 2310B loop • Submit the NPI (and, optionally, the tax ID) of the provider rendering the professional component in the rendering (2310B) loop. • For the technical component service, submit the NPI of the provider contracted with Blue Cross to render the technical component in the service rendering (2420A) loop. 837P CAA Surprise Billing (Consolidate Appropriations Act) 2022 Federal Mandate Blue Cross requires that a CMHC submit a procedure code modifier specific to the specialty of the rendering staff provider on each line of the claim. Blue Cross requires the following information in the 837P for the 2022 CAA surprise billing mandate: • The SERVICE FACILITY LOCATION NAME in loop 2310C is required when billing for professional services rendered by a non-participating provider in a participation facility. • The PWK (CLAIM SUPPLEMENTAL INFORMATION) segment in loop 2300 must also be populated using CK (Consent Form) when the member has signed a waiver consent form. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 71 Frequency Codes 5, 7, and 8 Guidelines Frequency code 5 (late charges) Institutional 837I claims You can use frequency 5 code on all claims, except Medicare Advantage claims. A late charge claim request: • Applies to one original claim (a 1:1 request) and must include only the additional services and/or charges that were not initially included on the original claim. • Must follow the same timely filing submission guidelines currently in place for original claims for any newly added services or late charges. Please refer to the Blue Book provider manual for detailed information about timely filing submission guidelines. When to use frequency code 5 When not to use frequency code 5 • When adding services that were not billed on the original transaction • To add units of service • EDI late charge requests require two fields at the loop 2300 level to be coded to process through the Blue Cross claims adjudication system o Claim segment, field CLM05-3 • Value 5 indicates a late charge Note: Alpha values are not acceptable for late charges o NTE segment, with qualifier ADD and the narrative that explains what is being added For example: “Add 3 new charges and add units of services to CPT or HCPCS code xxx” • On claims originally denied for exceeding the timely filing limit. Refer to our timely filing appeals guidelines in the Blue Book • If the original claim is processed and the late charges exceed the filing limit as outlined in the Blue Book • To change the type of bill on either a professional or facility claim, from inpatient to outpatient, or from outpatient to inpatient • On an 837P professional claim • For claims adjudication/resubmission if the claim is rejected on the EDI front-end. You must resubmit this type of claim as a new-day claim with frequency code 1 • For subscriber ID corrections. To correct a subscriber ID, please submit a new day claim with frequency code 1 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 72 • On Medicare Advantage claims, according to Section 110, Chapter 4 of the CMS Claims Processing Manual. Use frequency code 7 instead 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 73 Frequency code 7 (resubmission) An EDI replacement claim request: • Wait for the claim to process and finalize before you submit a replacement. • Applies to one original claim (a 1:1 request). • You cannot submit one replacement claim for multiple original claims. • Must be used to change previously submitted information. • Can be used for claims that include changes to the original claim, in addition to charges for services not previously submitted. However, it must meet the timely filing guidelines outlined in the Blue Book provider manual. • Requires 3 fields at the loop 2300 level to be coded in order to process through our claims adjudication system. • Claim segment, field CLM05-3 • Values 7 for Blue Cross replacement requests Note: Alpha values are not acceptable for replacement claims. • REF segment, use qualifier value F8. Provide the original claim number to be referenced. This is the claim number that Blue Cross assigned to your original submission. When to use frequency code 7 When not to use frequency code 7 • When you have corrected information for the original claim submitted. • If in addition to correcting information on the original claim you are adding services that were not billed on the original transaction. Use code 7 to update information in a field on the claim (if only adding late charges, please see separate instructions • When appealing or questioning pricing, benefits, or membership coverage dates on a claim. Follow the appeal guidelines in the Blue Book provider manual. • On claims originally denied for timely filing. Our Provider Service department manages timely filing appeals. Follow the appeal guidelines in the Blue Book provider manual. • For claims originally denied because attachments were not included, or for 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 74 When to use frequency code 7 When not to use frequency code 7 for the use of a	MPC_092315-4N___837_Companion_Guide.pdf
CPT or HCPCS code xxx” • On claims originally denied for exceeding the timely filing limit. Refer to our timely filing appeals guidelines in the Blue Book • If the original claim is processed and the late charges exceed the filing limit as outlined in the Blue Book • To change the type of bill on either a professional or facility claim, from inpatient to outpatient, or from outpatient to inpatient • On an 837P professional claim • For claims adjudication/resubmission if the claim is rejected on the EDI front-end. You must resubmit this type of claim as a new-day claim with frequency code 1 • For subscriber ID corrections. To correct a subscriber ID, please submit a new day claim with frequency code 1 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 72 • On Medicare Advantage claims, according to Section 110, Chapter 4 of the CMS Claims Processing Manual. Use frequency code 7 instead 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 73 Frequency code 7 (resubmission) An EDI replacement claim request: • Wait for the claim to process and finalize before you submit a replacement. • Applies to one original claim (a 1:1 request). • You cannot submit one replacement claim for multiple original claims. • Must be used to change previously submitted information. • Can be used for claims that include changes to the original claim, in addition to charges for services not previously submitted. However, it must meet the timely filing guidelines outlined in the Blue Book provider manual. • Requires 3 fields at the loop 2300 level to be coded in order to process through our claims adjudication system. • Claim segment, field CLM05-3 • Values 7 for Blue Cross replacement requests Note: Alpha values are not acceptable for replacement claims. • REF segment, use qualifier value F8. Provide the original claim number to be referenced. This is the claim number that Blue Cross assigned to your original submission. When to use frequency code 7 When not to use frequency code 7 • When you have corrected information for the original claim submitted. • If in addition to correcting information on the original claim you are adding services that were not billed on the original transaction. Use code 7 to update information in a field on the claim (if only adding late charges, please see separate instructions • When appealing or questioning pricing, benefits, or membership coverage dates on a claim. Follow the appeal guidelines in the Blue Book provider manual. • On claims originally denied for timely filing. Our Provider Service department manages timely filing appeals. Follow the appeal guidelines in the Blue Book provider manual. • For claims originally denied because attachments were not included, or for 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 74 When to use frequency code 7 When not to use frequency code 7 for the use of a frequency code value of 5). • When you have corrected information for the original claim submitted. • Here are some examples of reasons you may request a payment adjustment: − Corrected date of service − Revise previously submitted diagnosis codes, procedure, or modifiers − Correct patient data, except the Blue Cross Blue Shield of Massachusetts subscriber ID − Change the billed amount on the original claim − Correct a claim that denied for a referral or authorization, if one has been approved − We offer more details in our Replacement claim page on Provider Central, so please be sure to review the guide and share it with your IT team services that require additional documentation for review. • When submitting for late charges only. Please see separate instructions for the use of a frequency code value of 5. • To change the type of bill on a professional or facility claim from outpatient to inpatient, or from inpatient to outpatient. • For claims adjudication and resubmission if the claim is rejected on the EDI front-end. You must resubmit this type of claim as a new-day claim, with claim frequency = 1 (CLM05-3). • For subscriber ID corrections. To correct a subscriber ID, please submit a new day claim with claim frequency = 1 (CLM05-3) referenced. • Making changes to the billing NPI. • Making changes to a bridged claim. • Changing the dates of service if the revised dates fall outside the date span of the original claim. Back to top 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 75 Frequency code 8 (full void) When to use frequency code 8 When not to use frequency code 8 When submitting for a fully voided claim • EDI requests require two fields at the loop 2300 level to be coded to process through the Blue Cross claims adjudication system. o Claim segment, field CLM05-3 • Value 8 indicates Voided REF 02- Use qualifier value F8- provide original claim number to be referenced. For example • Must represent the entire claim—not just the line or item that you are retracting. • Must serve as a full void of the claim (a 1:1 request). You cannot submit one resubmission claim for multiple original claims. On fully denied claims* Exception: sometimes other plans require a full void on a denied claim. This would be done using frequency code 8. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 76 Massachusetts 837 claims for out-of-state Medicaid agencies Effective in April 2016, NPI and NDC fields are systematically required for participating providers. Use the table below to determine which loops are required for 837I and 837P. Field name Loop 837I 837P National drug code 2410 LIN03 X X Rendering provider identifier (NPI) 2310B NM109 unless overridden when reported in loop 2420A NM109 only when rendering is different from loop 2010AA billing provider X Rendering provider identifier (NPI) 2310D NM109 unless overridden when reported in loop 2420C NM109 only when rendering is different from loop 2310A attending Provider X Billing provider NPI 2010AA NM109 X X Billing provider (second) address line 2010AA N302 X X Billing provider middle name or initial 2010AA NM105 X X Billing provider taxonomy code 2000A PRV03 X X Rendering provider taxonomy code 2310B PRV03 unless overridden when reported in loop 2420A PRV03 X Service laboratory or facility postal zone or zip code Loop 2310C N403 unless overridden when reported in loop 2420C N403 X 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 77 Field name Loop 837I 837P Service laboratory or facility postal zone or zip code Loop 2310E N403 X Ambulance transport distance 2300 CR106 unless overridden when reported in loop 2400 CR106 X Ambulance transport distance 2400 SV205 with applicable revenue code X Service laboratory facility name 2310C NM103 unless overridden when reported in loop 2420C NM103 X Service laboratory facility name 2310E N402 X Value code amount 2300 HI in 5th position within the composite data element (value information HI) Up to 24 value codes may be reported with a corresponding amount X Value code 2300 HI in 2nd position within the composite data element (value information HI) Up to 24 value codes may be reported X Condition code 2300 HI in 2nd position within the composite data element (condition information HI) Up to 24 condition codes may be reported X X Occurrence codes and dates 2300 HI in 2nd and 4th positions within the composite data element (occurrence information HI) Up to 24 occurrence codes and associated dates may be reported X 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 78 Field name Loop 837I 837P Occurrence span codes and dates 2300 HI in 2nd and 4th positions within the composite data element (occurrence span information HI) Up to 24 occurrence codes and associated dates may be reported X Referring provider identifier and identification code qualifier 2310A NM108/09 or REF01/02 unless overridden when reported in loop 2420F NM108/09 or REF01/02 X Referring provider identifier and identification code qualifier 2310F NM108/09 or REF01/02 unless overridden when reported in loop 2420D NM108/09 or REF01/02 X Attending provider NPI 2310A NM109 X Operating physician NPI 2310B NM109 unless overridden when reported in loop 2420A NM108/09 X Claim or line note text 2300 NTE02 unless overridden when reported in loop 2400 NTE02 (Line Note NTE) X X Certification condition applies indicator and condition indicator (Early and periodic screening diagnosis and treatment (EPSDT) 2300 CRC02, CRC03 (EPSDT Referral CRC) loop 2300 CRC04 and CRC05 are used when additional conditions apply X X Service facility name and location Information 2310E X Ambulance transport information patient weight ambulance transport 2300 CR102 X 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 79 Field name Loop 837I 837P Reason code round trip purpose description stretcher purpose description CR104 CR109 CR110 X Ordering provider identifier and identification code qualifier 2420E NM108/09 or REF01/02 when a different from the service line rendering provider X Remittance date There are two options for the remittance date. It can either be on the claim level (2330B) or on the line level (2430). We typically see inpatient institutional remittance date on the claim level (2330B) and outpatient/professional on the line level (2430). A good practice when you’re building an MOA segment is to pass the remit date in the 2430 loop. If you are building an MIA segment, then pass it in the 2330B loop. • DTP01 = 573 • DTP02 = D8 • DTP03 = CCYYMMDD (Adjudication or Payment Date) Non-specific procedure codes require a narrative in service detail loop For non-specific procedure codes, HIPAA requires a narrative to be submitted in the narrative field in the service line loop/segment for the appropriate transaction: 837I, 837P, or 837D. If the narrative is not submitted for the non-specific procedure codes, the claim will reject back to the submitter stating that the sub-element for the narrative field is missing. Back to top 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 80 Revision history Version Date Updates made 1.2 Apr 2010 Update 837P billing instructions for professional and technical components for radiology services Enhance batch and claim submission guidelines. 1.2.1 Sep 30, 2011 Cover replaced: “HIPAA Transaction” with “Health Care Claim” 1.2.1a Nov 1, 2011 8.1 Corrected “Loop 2320” to “Loop 2430” for line deductible amount and line co-insurance amount items in Blue Cross Blue Shield of Massachusetts Coordination of Benefits Quick Reference table. 5.4 Added NEW section 5.4 Delimiters 1.2.2 Feb 3, 2012 Added new section 6 – Blue Cross Identification Number Requirements 7.1 Loop Specific Data – Added note to Loop 2310B (rendering provider name) with specific instructions 7.2 Loop Specific Data – Added new Loop 2310D (rendering provider name) with specific instructions 7.2 Loop Specific Data – HI Segment updated with language to include DTP segment (DTP01 = 435) if patient’s reason for visit is submitted on transaction 7.2 Loop Specific Data – HI Segment (present on admission) added to clarify differences between 5010 and 5010 submission. 10.1 Added new section 10.1 – Medicare as primary payer 1.2.3 May 15, 2012 7.2 Loop Specific Data – 2010BA NM1 revised for clarification. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 81 Version Date Updates made 10.2 Reworded paragraph to clarify submitter vs. dependent claims. 1.2.4 Jan 21, 2013 9 updated to include the requirement of remaining liability Amount (AMTEAF) segment when line level adjudication information is not included 1.2.5 Nov 19, 2015 Update 837P & 837I billing instructions for frequency codes 5 (late charges) & 7 (resubmissions) Update 837P & 837I billing instructions for in-state participating providers and submission of Medicaid out-of-state agency claims 1.2.6 Mar 2016 Updated for plain language and consistent formatting 1.3 May 22, 2017 Throughout: corrected numbering (eliminated “x.1” numbers; subsections under introduction began with “x.2”) 1.3 – Revised 2.2 – Removed the type of file	MPC_092315-4N___837_Companion_Guide.pdf
when a different from the service line rendering provider X Remittance date There are two options for the remittance date. It can either be on the claim level (2330B) or on the line level (2430). We typically see inpatient institutional remittance date on the claim level (2330B) and outpatient/professional on the line level (2430). A good practice when you’re building an MOA segment is to pass the remit date in the 2430 loop. If you are building an MIA segment, then pass it in the 2330B loop. • DTP01 = 573 • DTP02 = D8 • DTP03 = CCYYMMDD (Adjudication or Payment Date) Non-specific procedure codes require a narrative in service detail loop For non-specific procedure codes, HIPAA requires a narrative to be submitted in the narrative field in the service line loop/segment for the appropriate transaction: 837I, 837P, or 837D. If the narrative is not submitted for the non-specific procedure codes, the claim will reject back to the submitter stating that the sub-element for the narrative field is missing. Back to top 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 80 Revision history Version Date Updates made 1.2 Apr 2010 Update 837P billing instructions for professional and technical components for radiology services Enhance batch and claim submission guidelines. 1.2.1 Sep 30, 2011 Cover replaced: “HIPAA Transaction” with “Health Care Claim” 1.2.1a Nov 1, 2011 8.1 Corrected “Loop 2320” to “Loop 2430” for line deductible amount and line co-insurance amount items in Blue Cross Blue Shield of Massachusetts Coordination of Benefits Quick Reference table. 5.4 Added NEW section 5.4 Delimiters 1.2.2 Feb 3, 2012 Added new section 6 – Blue Cross Identification Number Requirements 7.1 Loop Specific Data – Added note to Loop 2310B (rendering provider name) with specific instructions 7.2 Loop Specific Data – Added new Loop 2310D (rendering provider name) with specific instructions 7.2 Loop Specific Data – HI Segment updated with language to include DTP segment (DTP01 = 435) if patient’s reason for visit is submitted on transaction 7.2 Loop Specific Data – HI Segment (present on admission) added to clarify differences between 5010 and 5010 submission. 10.1 Added new section 10.1 – Medicare as primary payer 1.2.3 May 15, 2012 7.2 Loop Specific Data – 2010BA NM1 revised for clarification. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 81 Version Date Updates made 10.2 Reworded paragraph to clarify submitter vs. dependent claims. 1.2.4 Jan 21, 2013 9 updated to include the requirement of remaining liability Amount (AMTEAF) segment when line level adjudication information is not included 1.2.5 Nov 19, 2015 Update 837P & 837I billing instructions for frequency codes 5 (late charges) & 7 (resubmissions) Update 837P & 837I billing instructions for in-state participating providers and submission of Medicaid out-of-state agency claims 1.2.6 Mar 2016 Updated for plain language and consistent formatting 1.3 May 22, 2017 Throughout: corrected numbering (eliminated “x.1” numbers; subsections under introduction began with “x.2”) 1.3 – Revised 2.2 – Removed the type of file transmission, “Broadcast messages” 2.4 – Updated NEHEN section with Trizetto NEHEN information 5.8 – Added new section 8.2 – Corrected code by removing extra “X” in 005010X222A1 (Professional Implementation Guide plus Addenda) 8.2 – For Service Facility Location, added the note “*If the NPI is not different then the NPI submitted in 2010AA do not send the NPI in this loop.” For NM101 / 98 8.2.1 – Corrected code by removing extra “X” in 005010X223A2 (Institutional Implementation Guide plus Addenda) 8.2.1 0 – New table for Rendering Provider 12 – New section 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 82 Version Date Updates made 13 – New section 1.3.1 Mar 1, 2018 9.1 –Updated to include information on COB Medicare submission of electronic claims 10.2 – Revised Frequency 5 information 10.3 – Revised Frequency 7 information 1.3.2 May 22, 2019 10.4 – Added Frequency 8 information 1.3.3 November 10, 2021 New template. Removed numbering. Minor language updates. Added section, “837P CAA Surprise Billing (Consolidate Appropriations Act) 2022 Federal Mandate” 1.4 February 10, 2023 Added “Please note: Your organization’s SFTP folder will be created using your submitter; for example, e:\company\tradingpartners\(submitter id). This folder path will be shared with your organization” to first Tumbleweed bullet on page 11. 1.5 February 28, 2024 Clarified the section, “Facility code requirements for 837P and 837I claims for Blue Cross” Back to top	MPC_092315-4N___837_Companion_Guide.pdf
Stedi maintains this guide based on public documentation from Anthem. Contact Anthem for official EDI specifications. To report any errors in this guide, please contact us. X12 835 Health Care Claim Payment/Advice (X221A1) X12 Release 5010 Revised March 1, 2024 Go to Stedi Network 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 View the latest version of this implementation guide as an interactive webpage https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice- x221a1/01HQWPEZE89AKHP7SZ7YAE893C POWERED BY Build EDI implementation guides at stedi.com 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 1/127 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 Payer Identification Loop N1 0800 Payer Identification Max use 1 Required N3 1000 Payer Address Max use 1 Required N4 1100 Payer City, State, ZIP Code Max use 1 Required REF 1200 Additional Payer Identification Max use 4 Optional PER 1300 Payer Business Contact Information Max use 1 Optional PER 1300 Payer Technical Contact Information Max use 1 Required PER 1300 Payer WEB Site Max use 1 Optional Payee Identification Loop N1 0800 Payee Identification Max use 1 Required N3 1000 Payee Address Max use 1 Optional N4 1100 Payee City, State, ZIP Code Max use 1 Optional REF 1200 Payee Additional Identification Max use 1 Optional RDM 1400 Remittance Delivery Method Max use 1 Optional 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 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 2/127 Claim Payment Information Loop CLP 0100 Claim Payment Information Max use 1 Required CAS 0200 Claim Adjustment Max use 99 Optional NM1 0300 Corrected Patient/Insured Name Max use 1 Optional NM1 0300 Corrected Priority Payer Name Max use 1 Optional NM1 0300 Crossover Carrier Name Max use 1 Optional NM1 0300 Insured Name Max use 1 Optional NM1 0300 Other Subscriber Name Max use 1 Optional NM1 0300 Patient Name Max use 1 Required NM1 0300 Service Provider Name Max use 1 Optional MIA 0330 Inpatient Adjudication Information Max use 1 Optional MOA 0350 Outpatient Adjudication Information Max use 1 Optional REF 0400 Other Claim Related Identification Max use 5 Optional REF 0400 Rendering Provider Identification Max use 10 Optional DTM 0500 Claim Received Date Max use 1 Optional DTM 0500 Coverage Expiration Date Max use 1 Optional DTM 0500 Statement From or To Date Max use 2 Optional PER 0600 Claim Contact Information Max use 2 Optional AMT 0620 Claim Supplemental Information Max use 13 Optional QTY 0640 Claim Supplemental Information Quantity Max use 14 Optional Service Payment Information Loop SVC 0700 Service Payment Information Max use 1 Required DTM 0800 Service Date Max use 2 Optional CAS 0900 Service Adjustment Max use 99 Optional REF 1000 HealthCare Policy Identification Max use 5 Optional REF 1000 Line Item Control Number Max use 1 Optional REF 1000 Rendering Provider Information Max use 10 Optional REF 1000 Service Identification Max use 8 Optional AMT 1100 Service Supplemental Amount Max use 9 Optional QTY 1200 Service Supplemental Quantity Max use 6 Optional LQ 1300 Health Care Remark Codes Max use 99 Optional 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 3/127 Summary PLB 0100 Provider Adjustment Max use 1 Optional SE 0200 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 4/127 ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange- related control segments Example ISA00 00 XXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXX2501301720^0050100000000 0XX>~ Max use 1 Required ISA-01 I01 Authorization Information Qualifier Identifier (ID) 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 Min 10 Max 10 String (AN) Required 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 Identifier (ID) 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 Min 10 Max 10 String (AN) Required 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 Min 2 Max 2 Identifier (ID) Required 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 Min 15 Max 15 String (AN) Required 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 Min 2 Max 2 Identifier (ID) Required 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 5/127 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 Min 15 Max 15 String (AN) Required 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 YYMMDD format Date (DT) Required Date of the interchange ISA-10 I09 Interchange Time HHMM format Time (TM) Required Time of the interchange ISA-11 I65 Repetition Separator Min 1 Max 1 String (AN) Required 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 Identifier (ID) 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 Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender ISA-14 I13 Acknowledgment Requested Min 1 Max 1 Identifier (ID) Required 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 Min 1 Max 1 Identifier (ID) Required Code indicating whether data enclosed by this interchange envelope is test, production or information I Information 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 6/127 P Production Data T Test Data ISA-16 I15 Component Element Separator Min 1 Max 1 String (AN) Required 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 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 7/127 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GSHPXXXXXXXXXXXX2025013018460000X005010X2 21A1~ Max use 1 Required GS-01 479 Functional Identifier Code Identifier (ID) Required Code identifying a group of application related transaction sets HP Health Care Claim Payment/Advice (835) GS-02 142 Application Sender's Code Min 2 Max 15 String (AN) Required Code identifying party sending transmission; codes agreed to by trading partners GS-03 124 Application Receiver's Code Min 2 Max 15 String (AN) Required Code identifying party receiving transmission; codes agreed to by trading partners GS-04 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year GS-05 337 Time HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time (TM) Required 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 Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required 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 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 8/127 GS-08 480 Version / Release / Industry Identifier Code String (AN) 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 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 9/127 Heading ST 0100 Heading > ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST8350001~ Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) 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 Min 4 Max 9 Numeric (N) Required 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. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 10/127 BPR 0200 Heading > BPR Financial Information To indicate the beginning of a Payment Order/Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and/or information from payer to payee to occur 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 BPRD00000CCHKCTX01XXXXXDAXXXXXXXXXXXX XXXXXXXXXX01XXXXXXXXSGXXX20250130~ If either Depository Financial Institution (DFI) Identification Number Qualifier (BPR-06) or Sender DFI	Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
= 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 Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required 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 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 8/127 GS-08 480 Version / Release / Industry Identifier Code String (AN) 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 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 9/127 Heading ST 0100 Heading > ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST8350001~ Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) 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 Min 4 Max 9 Numeric (N) Required 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. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 10/127 BPR 0200 Heading > BPR Financial Information To indicate the beginning of a Payment Order/Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and/or information from payer to payee to occur 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 BPRD00000CCHKCTX01XXXXXDAXXXXXXXXXXXX XXXXXXXXXX01XXXXXXXXSGXXX20250130~ 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 Max use 1 Required BPR-01 305 Transaction Handling Code Identifier (ID) 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. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 11/127 BPR-02 782 Total Actual Provider Payment Amount Min 1 Max 15 Decimal number (R) Required 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 Identifier (ID) 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 Identifier (ID) 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 Identifier (ID) Optional Code identifying the payment format to be used CCP Cash Concentration/Disbursement plus Addenda (CCD+) (ACH) 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 12/127 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 Identifier (ID) 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 Min 3 Max 12 String (AN) Optional 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 Identifier (ID) 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 Min 1 Max 35 String (AN) Optional 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 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 13/127 Use this number for the originator's account number at the financial institution. BPR-10 509 Payer Identifier Min 10 Max 10 String (AN) Optional 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 Min 9 Max 9 String (AN) Optional 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 Identifier (ID) 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 Min 3 Max 12 String (AN) Optional 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 Identifier (ID) 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. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 14/127 DA Demand Deposit SG Savings BPR-15 508 Receiver or Provider Account Number Min 1 Max 35 String (AN) Optional 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 CCYYMMDD format Date (DT) Required 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	Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
Deposit BPR-09 508 Sender Bank Account Number Min 1 Max 35 String (AN) Optional 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 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 13/127 Use this number for the originator's account number at the financial institution. BPR-10 509 Payer Identifier Min 10 Max 10 String (AN) Optional 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 Min 9 Max 9 String (AN) Optional 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 Identifier (ID) 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 Min 3 Max 12 String (AN) Optional 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 Identifier (ID) 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. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 14/127 DA Demand Deposit SG Savings BPR-15 508 Receiver or Provider Account Number Min 1 Max 35 String (AN) Optional 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 CCYYMMDD format Date (DT) Required 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. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 15/127 TRN 0400 Heading > TRN Reassociation Trace Number 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 TRN1XXXXXXXXXXXXXXXXX~ Max use 1 Required TRN-01 481 Trace Type Code Identifier (ID) Required Code identifying which transaction is being referenced 1 Current Transaction Trace Numbers TRN-02 127 Check or EFT Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 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 Min 10 Max 10 String (AN) Required 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 Min 1 Max 50 String (AN) Optional 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 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 16/127 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. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 17/127 CUR 0500 Heading > CUR Foreign Currency Information 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 CURPRXXX~ Max use 1 Optional CUR-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer CUR-02 100 Currency Code Min 3 Max 3 Identifier (ID) Required Code (Standard ISO) for country in whose currency the charges are specified Usage notes This is the currency code for the payment currency. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 18/127 REF 0600 Heading > REF Receiver Identification 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 REFEVXX~ Variants (all may be used) REF Version Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EV Receiver Identification Number REF-02 127 Receiver Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 19/127 REF 0600 Heading > REF Version Identification 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 REFF2XX~ Variants (all may be used) REF Receiver Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F2 Version Code - Local REF-02 127 Version Identification Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 20/127 DTM 0700 Heading > DTM Production Date 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 DTM40520250130~ Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 405 Production DTM-02 373 Production Date CCYYMMDD format Date (DT) Required 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. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 21/127 1000A Payer Identification Loop Max 1 Required Variants (all may be used) Payee Identification Loop N1 0800 Heading > Payer Identification Loop > N1 Payer Identification 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 N1PRXXXVXX~ If either Identification Code Qualifier (N1-03) or Payer Identifier (N1-04) is present, then the other is required Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer N1-02 93 Payer Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) 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 Min 2 Max 80 String (AN) Optional 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. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 22/127 N3 1000 Heading > Payer Identification Loop > N3 Payer Address To specify the location of the named party Example N3XXXXXXXX~ Max use 1 Required N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 23/127 N4 1100 Heading > Payer Identification Loop > N4 Payer City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXXXXXX~ 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 Max use 1 Required N4-01 19 Payer City Name Min 2 Max 30 String (AN) Required 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 Min 2 Max 2 Identifier (ID) Optional 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 Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country	Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 21/127 1000A Payer Identification Loop Max 1 Required Variants (all may be used) Payee Identification Loop N1 0800 Heading > Payer Identification Loop > N1 Payer Identification 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 N1PRXXXVXX~ If either Identification Code Qualifier (N1-03) or Payer Identifier (N1-04) is present, then the other is required Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer N1-02 93 Payer Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) 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 Min 2 Max 80 String (AN) Optional 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. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 22/127 N3 1000 Heading > Payer Identification Loop > N3 Payer Address To specify the location of the named party Example N3XXXXXXXX~ Max use 1 Required N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 23/127 N4 1100 Heading > Payer Identification Loop > N4 Payer City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXXXXXX~ 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 Max use 1 Required N4-01 19 Payer City Name Min 2 Max 30 String (AN) Required 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 Min 2 Max 2 Identifier (ID) Optional 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 Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 24/127 REF 1200 Heading > Payer Identification Loop > REF Additional Payer Identification 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 REF2UXXX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) 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 Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 25/127 PER 1300 Heading > Payer Identification Loop > PER Payer Business Contact Information 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 PERCXXXXTEXXXXTEXEXXXXXXX~ Variants (all may be used) PER Payer Technical Contact Information PER Payer WEB Site 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 Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Payer Contact Name Min 1 Max 60 String (AN) Optional 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 Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 26/127 PER-04 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail 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 Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 27/127 PER 1300 Heading > Payer Identification Loop > PER Payer Technical Contact Information 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 PERBLXXXXXEMXXXEMXXXXXXFXXXX~ Variants (all may be used) PER Payer Business Contact Information PER Payer WEB Site 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 Max use >1 Required PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named BL Technical Department PER-02 93 Payer Technical Contact Name Min 1 Max 60 String (AN) Optional 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 Identifier (ID) 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 Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 28/127 PER-05 365 Communication Number Qualifier Identifier (ID) 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 Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number 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 Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 29/127 1000A Payer Identification Loop end PER 1300 Heading > Payer Identification Loop > PER Payer WEB Site 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 PERICURXXX~ Variants (all may be used) PER Payer Business Contact Information PER Payer Technical Contact Information Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number UR Uniform Resource Locator (URL) PER-04 364 Communication Number Min 1 Max 256 String (AN) Required 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. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 30/127 1000B Payee Identification Loop Max 1 Required Variants (all may be used) Payer Identification Loop N1 0800 Heading > Payee Identification Loop > N1 Payee Identification 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 N1PEXXXVXXXXX~ Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PE Payee N1-02 93 Payee Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) Required 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). 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	Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 28/127 PER-05 365 Communication Number Qualifier Identifier (ID) 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 Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number 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 Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 29/127 1000A Payer Identification Loop end PER 1300 Heading > Payer Identification Loop > PER Payer WEB Site 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 PERICURXXX~ Variants (all may be used) PER Payer Business Contact Information PER Payer Technical Contact Information Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number UR Uniform Resource Locator (URL) PER-04 364 Communication Number Min 1 Max 256 String (AN) Required 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. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 30/127 1000B Payee Identification Loop Max 1 Required Variants (all may be used) Payer Identification Loop N1 0800 Heading > Payee Identification Loop > N1 Payee Identification 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 N1PEXXXVXXXXX~ Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PE Payee N1-02 93 Payee Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) Required 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). 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 Min 2 Max 80 String (AN) Required 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. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 31/127 N3 1000 Heading > Payee Identification Loop > N3 Payee Address 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 N3XXXXXX~ Max use 1 Optional N3-01 166 Payee Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payee Address Line Min 1 Max 55 String (AN) Optional Address information 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 32/127 N4 1100 Heading > Payee Identification Loop > N4 Payee City, State, ZIP Code 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 N4XXXXXXXXXXXXXXXX~ 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 Max use 1 Optional N4-01 19 Payee City Name Min 2 Max 30 String (AN) Required 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 Min 2 Max 2 Identifier (ID) Optional 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 Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 33/127 REF 1200 Heading > Payee Identification Loop > REF Payee Additional Identification 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 REFD3XXXXX~ Max use >1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number D3 National Council for Prescription Drug Programs Pharmacy Number PQ Payee Identification REF-02 127 Additional Payee Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 34/127 RDM 1400 Heading > Payee Identification Loop > RDM Remittance Delivery Method 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 RDMOLXX~ Max use 1 Optional RDM-01 756 Report Transmission Code Identifier (ID) 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 Min 1 Max 60 String (AN) Optional 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 Min 1 Max 256 String (AN) Optional 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 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 35/127 1000B Payee Identification Loop end Heading end Contains URL web address or e-mail address. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 36/127 Detail 2000 Header Number Loop Max >1 Optional LX 0030 Detail > Header Number Loop > LX Header Number 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 LX00~ Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 37/127 TS3 0050 Detail > Header Number Loop > TS3 Provider Summary Information 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 TS3XXXXXXX2025013000000000000000*****0000 00000000000000000*00000000000000000*00000000 00000000000000000000000*00000000000~ Max use 1 Optional TS3-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TS301 is the provider number. Usage notes This is the provider number. TS3-02 1331 Facility Type Code Min 1 Max 2 String (AN) Required 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 CCYYMMDD format Date (DT) Required 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 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 38/127 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 Min 1 Max 15 Decimal number (R) Required 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 Min 1 Max 15 Decimal number (R) Required 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	Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
service level segments. This number is intended to be unique within each transaction. Example LX00~ Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 37/127 TS3 0050 Detail > Header Number Loop > TS3 Provider Summary Information 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 TS3XXXXXXX2025013000000000000000******0000 00000000000000000*00000000000000000*00000000 0000000000000000000000000000000000~ Max use 1 Optional TS3-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TS301 is the provider number. Usage notes This is the provider number. TS3-02 1331 Facility Type Code Min 1 Max 2 String (AN) Required 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 CCYYMMDD format Date (DT) Required 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 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 38/127 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 Min 1 Max 15 Decimal number (R) Required 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 Min 1 Max 15 Decimal number (R) Required 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS315 is the summary of non-lab charges. Usage notes See TR3 note 3. TS3-17 782 Total HCPCS Reported Charge Amount Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 39/127 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS322 is the total patient reimbursement. Usage notes See TR3 note 3. TS3-23 380 Total PIP Claim Count Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS324 is total periodic interim payment (PIP) adjustment. Usage notes 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 40/127 See TR3 note 3. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 41/127 TS2 0070 Detail > Header Number Loop > TS2 Provider Supplemental Summary Information 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 TS20000000000000000000000000000000000000000 00000000000000000000000000000000000000000000 000000000000000000000000000000000000000000 00000000000000000000~ Max use 1 Optional TS2-01 782 Total DRG Amount Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS202 is the total federal specific amount. Usage notes See TR3 note 2. TS2-03 782 Total Hospital Specific Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS203 is the total hospital specific amount. Usage notes See TR3 note 2. TS2-04 782 Total Disproportionate Share Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS204 is the total disproportionate share amount. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 42/127 Usage notes See TR3 note 2. TS2-05 782 Total Capital Amount Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS206 is the total indirect medical education amount. Usage notes See TR3 note 2. TS2-07 380 Total Outlier Day Count Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS208 is the total day outlier amount. Usage notes See TR3 note 2. TS2-09 782 Total Cost Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS209 is the total cost outlier amount. Usage notes See TR3 note 2. TS2-10 380 Average DRG Length of Stay Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 43/127 TS210 is the diagnosis related group (DRG) average length of stay. Usage notes See TR3 note 2. TS2-11 380 Total Discharge Count Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 44/127 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS219 is the total prospective payment system (PPS) disproportionate share, hospital diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 45/127 2100 Claim Payment Information Loop Max >1 Required CLP 0100 Detail > Header Number Loop > Claim Payment Information Loop > CLP Claim Payment Information 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 CLPXX2000000000000000000000000000000000000 0MAXXXXXX00000000*0000~ Max use 1 Required CLP-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required 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 Identifier (ID) 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	Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
note 2. TS2-16 380 Average DRG weight Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 44/127 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS219 is the total prospective payment system (PPS) disproportionate share, hospital diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 45/127 2100 Claim Payment Information Loop Max >1 Required CLP 0100 Detail > Header Number Loop > Claim Payment Information Loop > CLP Claim Payment Information 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 CLPXX2000000000000000000000000000000000000 0MAXXXXXX000000000000~ Max use 1 Required CLP-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required 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 Identifier (ID) 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) 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 46/127 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 Min 1 Max 15 Decimal number (R) Required 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 Min 1 Max 15 Decimal number (R) Required Monetary amount CLP04 is the amount paid this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. See section 1.10.2.9 for information about interest considerations. Use this monetary amount for the amount paid for this claim. It can be positive, zero or negative, but the value in BPR02 may not be negative. CLP-05 782 Patient Responsibility Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CLP05 is the patient responsibility amount. Usage notes Amounts in CLP05 must have supporting adjustments reflected in CAS segments at the 2100 (CLP) or 2110 (SVC) loop level with a Claim Adjustment Group (CAS01) code of PR (Patient Responsibility). Use this monetary amount for the payer's statement of the patient responsibility amount for this claim, which can include such items as deductible, non-covered services, co-pay and co-insurance. This is not used for reversals. See section 1.10.2.8, Reversals and Corrections, for additional information. CLP-06 1032 Claim Filing Indicator Code Identifier (ID) Required 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 47/127 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 Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CLP07 is the payer's internal control number. Usage notes 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 48/127 Use this number for the payer's internal control number. This number must apply to the entire claim. CLP-08 1331 Facility Type Code Min 1 Max 2 String (AN) Optional Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. Usage notes Since professional or dental claims can have different place of service codes for services within a single claim, default to the place of service of the first service line when the service lines are not all for the same place of service. This number was received in CLM05-1 of the 837 claim. CLP-09 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Optional Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type Usage notes This number was received in CLM05-3 of the 837 Claim. CLP-11 1354 Diagnosis Related Group (DRG) Code Min 1 Max 4 Identifier (ID) Optional Code indicating a patient's diagnosis group based on a patient's illness, diseases, and medical problems CLP-12 380 Diagnosis Related Group (DRG) Weight Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CLP12 is the diagnosis-related group (DRG) weight. Usage notes This is the adjudicated DRG Weight. CLP-13 954 Discharge Fraction Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%) CLP13 is the discharge fraction. Usage notes This is the adjudicated discharge fraction. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 49/127 CAS 0200 Detail > Header Number Loop > Claim Payment Information Loop > CAS Claim Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Payers must use this CAS segment to report claim level adjustments that cause the amount paid to differ from the amount originally charged. See 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. See the SVC TR3 Note #1 for details about per diem adjustments. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment must be the first non-zero adjustment and is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Required when dollar amounts and/or quantities are being adjusted at the claim level. If not required by this implementation guide, do not send. Example CASPRXX00000X000000000000000000000000000 0XXXXX0000000000000000XXX000X000000000000 00000000000000XXX00000000000000~ 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	Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
Group (DRG) Code Min 1 Max 4 Identifier (ID) Optional Code indicating a patient's diagnosis group based on a patient's illness, diseases, and medical problems CLP-12 380 Diagnosis Related Group (DRG) Weight Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CLP12 is the diagnosis-related group (DRG) weight. Usage notes This is the adjudicated DRG Weight. CLP-13 954 Discharge Fraction Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%) CLP13 is the discharge fraction. Usage notes This is the adjudicated discharge fraction. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 49/127 CAS 0200 Detail > Header Number Loop > Claim Payment Information Loop > CAS Claim Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Payers must use this CAS segment to report claim level adjustments that cause the amount paid to differ from the amount originally charged. See 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. See the SVC TR3 Note #1 for details about per diem adjustments. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment must be the first non-zero adjustment and is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Required when dollar amounts and/or quantities are being adjusted at the claim level. If not required by this implementation guide, do not send. Example CASPRXX00000X000000000000000000000000000 0XXXXX0000000000000000XXX000X000000000000 00000000000000XXX00000000000000~ If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS- 07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 50/127 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer/payee contractual agreement or a regulatory requirement resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. 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 Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the claim level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes See section 1.10.2.4.1 for additional information. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 51/127 A positive value decreases the covered days, and a negative number increases the covered days. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 52/127 Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 53/127 Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 54/127 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Corrected Patient/Insured Name To supply the full name of an individual or organizational entity Usage notes Since the patient is always the insured for Medicare and Medicaid, this segment always provides corrected patient information for Medicare and Medicaid. For other carriers, this will always be the corrected insured information. Required when needed to provide corrected information about the patient or insured. If not required by this implementation guide, do not send. Example NM1741XXXXXX*XXXCXXX~ Variants (all may be used) NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured Name NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Corrected Insured Identification Indicator (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 74 Corrected Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Corrected Patient or Insured Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Corrected Patient or Insured First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Corrected Patient or Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 55/127 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Corrected Patient or Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) C Insured's Changed Unique Identification Number NM1-09 67 Corrected Insured Identification Indicator Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 56/127 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Corrected Priority Payer Name To supply the full name of an individual or organizational entity Usage notes Provide any reference numbers in NM109. Use of this segment identifies the priority payer. Do not use this segment when the Crossover Carrier NM1 segment is used. Required when current payer believes that another payer has priority for making a payment and the claim is not being automatically transferred to that payer. If not required by this implementation guide, do not send. Example NM1PR2XXXXXX****FIXXXXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Crossover Carrier Name NM1 Insured Name NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Corrected Priority Payer Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) AD Blue Cross Blue Shield Association Plan Code FI Federal Taxpayer's Identification Number NI National Association of Insurance Commissioners (NAIC) Identification This is the preferred ID unless XV is used. PI Payor Identification PP Pharmacy Processor Number XV Centers for Medicare and Medicaid Services PlanID 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 57/127 Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used. NM1-09 67 Corrected Priority Payer Identification Number Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/29/25, 8:52	Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Corrected Patient or Insured Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Corrected Patient or Insured First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Corrected Patient or Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 55/127 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Corrected Patient or Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) C Insured's Changed Unique Identification Number NM1-09 67 Corrected Insured Identification Indicator Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 56/127 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Corrected Priority Payer Name To supply the full name of an individual or organizational entity Usage notes Provide any reference numbers in NM109. Use of this segment identifies the priority payer. Do not use this segment when the Crossover Carrier NM1 segment is used. Required when current payer believes that another payer has priority for making a payment and the claim is not being automatically transferred to that payer. If not required by this implementation guide, do not send. Example NM1PR2XXXXXX***FIXXXXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Crossover Carrier Name NM1 Insured Name NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Corrected Priority Payer Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) AD Blue Cross Blue Shield Association Plan Code FI Federal Taxpayer's Identification Number NI National Association of Insurance Commissioners (NAIC) Identification This is the preferred ID unless XV is used. PI Payor Identification PP Pharmacy Processor Number XV Centers for Medicare and Medicaid Services PlanID 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 57/127 Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used. NM1-09 67 Corrected Priority Payer Identification Number Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 58/127 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Crossover Carrier Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the crossover carrier. Provide any reference numbers in NM109. The crossover carrier is defined as any payer to which the claim is transferred for further payment after being finalized by the current payer. Required when the claim is transferred to another carrier or coverage (CLP02 equals 19, 20, 21 or 23). If not required by this implementation guide, do not send. Example NM1TT2XXXXXX***FIXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Insured Name NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual TT Transfer To NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Crossover Carrier Name Min 1 Max 60 String (AN) Required Individual last name or organizational name Usage notes Name of the crossover carrier associated with this claim. NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) 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 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 59/127 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 Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 60/127 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Insured Name 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 NM1IL2XXXXXXXXXXXXXXIIXXXXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Subscriber Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 61/127 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 Min 1 Max 10 String (AN) Optional 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 Identifier (ID) 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 Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 62/127 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes This is the name and ID number of the other subscriber when a corrected priority payer has been identified. When used, either the name or ID must be supplied. Required when a corrected priority payer has been identified in another NM1 segment AND the name or ID of the other subscriber is known. If not required by this implementation guide, do not send. Example NM1GB1XXXXXXXXXX*XXXXXXMIXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured Name NM1 Patient Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Other Subscriber Identifier (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual GB Other Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Subscriber Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name Usage notes At least one of NM103 or NM109 must be present. NM1-04 1036 Other Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 63/127 Individual middle name or initial Usage notes When only one character is present this is assumed to be the middle initial. NM1-07 1039 Other Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Not Used when NM102=1. II Standard Unique Health Identifier for each Individual in the United States Use this code if mandated in a final Federal Rule. MI Member Identification Number Use this code when supplying the number used for identification of the subscriber in NM109. NM1-09 67 Other Subscriber Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes At least one of NM103 or NM109 must be present. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 64/127 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Patient Name To supply the full name of an individual or organizational entity Usage notes Provide the patient's identification number in NM109. This segment must provide the information from the original claim. For example, when the claim is submitted as an ASC X12 837 transaction, this is the 2010CA loop NM1 Patient Name Segment unless not present on the original claim, then it is the 2010BA loop NM1 Subscriber name segment. The Corrected Patient/Insured Name NM1 segment identifies the adjudicated Insured Name and ID information if different than what was submitted on the claim. Example NM1QC1XXXXXXXXXXXX*XXXXXXII*XXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured Name NM1 Other Subscriber Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Patient Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual QC Patient NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Patient Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Patient First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Patient Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 65/127 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07	Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
Optional Individual last name or organizational name Usage notes At least one of NM103 or NM109 must be present. NM1-04 1036 Other Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 63/127 Individual middle name or initial Usage notes When only one character is present this is assumed to be the middle initial. NM1-07 1039 Other Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Not Used when NM102=1. II Standard Unique Health Identifier for each Individual in the United States Use this code if mandated in a final Federal Rule. MI Member Identification Number Use this code when supplying the number used for identification of the subscriber in NM109. NM1-09 67 Other Subscriber Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes At least one of NM103 or NM109 must be present. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 64/127 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Patient Name To supply the full name of an individual or organizational entity Usage notes Provide the patient's identification number in NM109. This segment must provide the information from the original claim. For example, when the claim is submitted as an ASC X12 837 transaction, this is the 2010CA loop NM1 Patient Name Segment unless not present on the original claim, then it is the 2010BA loop NM1 Subscriber name segment. The Corrected Patient/Insured Name NM1 segment identifies the adjudicated Insured Name and ID information if different than what was submitted on the claim. Example NM1QC1XXXXXXXXXXXXXXXXXXIIXXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured Name NM1 Other Subscriber Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Patient Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual QC Patient NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Patient Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Patient First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Patient Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 65/127 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Patient Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes An example of this is when a Junior and Senior are covered under the same subscriber. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) 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 Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 66/127 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Service Provider Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the rendering provider. An identification number is provided in NM109. This information is provided to facilitate identification of the claim within a payee's system. Other providers (e.g., Referring provider, supervising provider) related to the claim but not directly related to the payment are not supported and are not necessary for claim identification. Required when the rendering provider is different from the payee. If not required by this implementation guide, do not send. Example NM1822XXXXXXXXXXX*XXXXXSLXXXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured Name NM1 Other Subscriber Name NM1 Patient Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 67/127 Individual middle name or initial Usage notes If this data element is used and contains only one character, it represents the middle initial. NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) BD Blue Cross Provider Number BS Blue Shield Provider Number MC Medicaid Provider Number PC Provider Commercial Number SL State License Number UP Unique Physician Identification Number (UPIN) XX Centers for Medicare and Medicaid Services National Provider Identifier Required value if the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate. Otherwise, one of the other listed codes may be used. NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 68/127 MIA 0330 Detail > Header Number Loop > Claim Payment Information Loop > MIA Inpatient Adjudication Information To provide claim-level data related to the adjudication of Medicare inpatient claims Usage notes When used outside of the Medicare and Medicaid community only MIA01, 05, 20, 21, 22 and 23 may be used. Either MIA or MOA may appear, but not both. This segment must not be used for covered days or lifetime reserve days. For covered or lifetime reserve days, use the Supplemental Claim Information Quantities Segment in the Claim Payment Loop. All situational quantities and/or monetary amounts in this segment are required when the value of the item is different than zero. Required for all inpatient claims when there is a need to report Remittance Advice Remark Codes at the claim level or, the claim is paid by Medicare or Medicaid under the Prospective Payment System (PPS). If not required by this implementation guide, do not send. Example MIA00000000000000000XXXXX000000000000000 0000000000000000000000000000000000000000000 0000000000000000000000000000000000000XXXX XXXXXXXXXX*000000~ Max use 1 Optional MIA-01 380 Covered Days or Visits Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity MIA01 is the covered days. Usage notes Implementers utilizing the MIA segment always transmit the number zero. See the QTY segment at the claim level for covered days or visits count. MIA-02 782 PPS Operating Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA02 is the Prospective Payment System (PPS) Operating Outlier amount. Usage notes See TR3 note 4. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MIA-03 380 Lifetime Psychiatric Days Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA03 is the lifetime psychiatric days. MIA-04 782 Claim DRG Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 69/127 Monetary amount MIA04 is the Diagnosis Related Group (DRG) amount. MIA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA05 is the Claim Payment Remark Code. See Code Source 411. MIA-06 782 Claim Disproportionate Share Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA06 is the disproportionate share amount. MIA-07 782 Claim MSP Pass-through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA07 is the Medicare Secondary Payer (MSP) pass-through amount. MIA-08 782 Claim PPS Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA08 is the total Prospective Payment System (PPS) capital amount. MIA-09 782 PPS-Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 70/127 Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA19 is the professional component amount billed but not payable. MIA-20 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 71/127 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA20 is the Claim Payment Remark Code. See Code Source 411. MIA-21 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA21 is the Claim Payment Remark Code. See Code Source 411. MIA-22 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 72/127 MOA 0350 Detail	Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 70/127 Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA19 is the professional component amount billed but not payable. MIA-20 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 71/127 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA20 is the Claim Payment Remark Code. See Code Source 411. MIA-21 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA21 is the Claim Payment Remark Code. See Code Source 411. MIA-22 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 72/127 MOA 0350 Detail > Header Number Loop > Claim Payment Information Loop > MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required for outpatient/professional claims where there is a need to report a Remittance Advice Remark Code at the claim level or when the payer is Medicare or Medicaid and MOA01, 02, 08 or 09 are non-zero. If not required by this implementation guide, do not send. Either MIA or MOA may appear, but not both. All situational quantities and/or monetary amounts in this segment are;required when the value of the item is different than zero. Example MOA000000000000000000XXXXXXXXXXXXXXXXXXXX XXXXX0000000000000000000000~ Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%) MOA01 is the reimbursement rate. MOA-02 782 Claim HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 73/127 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 Claim ESRD Payment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 74/127 REF 0400 Detail > Header Number Loop > Claim Payment Information Loop > REF Other Claim Related Identification To specify identifying information Usage notes Required when additional reference numbers specific to the claim in the CLP segment are provided to identify information used in the process of adjudicating this claim. If not required by this implementation guide, do not send. Example REF1WX~ Variants (all may be used) REF Rendering Provider Identification Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) 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. REF-02 127 Other Claim Related Identifier Min 1 Max 50 String (AN) Required 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 75/127 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 76/127 REF 0400 Detail > Header Number Loop > Claim Payment Information Loop > REF Rendering Provider Identification 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 REF0BXX~ Variants (all may be used) REF Other Claim Related Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) 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 Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 77/127 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Claim Received Date To specify pertinent dates and times Usage notes Required whenever state or federal regulations or the provider contract mandate interest payment or prompt payment discounts based upon the receipt date of the claim by the payer. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example DTM05020250130~ Variants (all may be used) DTM Coverage Expiration Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the date that the claim was received by the payer. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 78/127 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Coverage Expiration Date To specify pertinent dates and times Usage notes Required when payment is denied because of the expiration of coverage. If not required by this implementation guide, do not send. Example DTM036*20250130~ Variants (all may be used) DTM Claim Received Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 036 Expiration DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the expiration date of the patient's coverage. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 79/127 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Statement From or To Date To specify pertinent dates and times Usage notes Dates at the claim level apply to the entire claim, including all service lines. Dates at the service line level apply only to the service line where they appear. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. For retail pharmacy claims, the Claim Statement Period Start Date is equivalent to the prescription filled date. Required when the "Statement From or To Dates" are not supplied at the service (2110 loop) level. If not required	Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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 Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 77/127 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Claim Received Date To specify pertinent dates and times Usage notes Required whenever state or federal regulations or the provider contract mandate interest payment or prompt payment discounts based upon the receipt date of the claim by the payer. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example DTM05020250130~ Variants (all may be used) DTM Coverage Expiration Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the date that the claim was received by the payer. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 78/127 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Coverage Expiration Date To specify pertinent dates and times Usage notes Required when payment is denied because of the expiration of coverage. If not required by this implementation guide, do not send. Example DTM03620250130~ Variants (all may be used) DTM Claim Received Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 036 Expiration DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the expiration date of the patient's coverage. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 79/127 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Statement From or To Date To specify pertinent dates and times Usage notes Dates at the claim level apply to the entire claim, including all service lines. Dates at the service line level apply only to the service line where they appear. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. For retail pharmacy claims, the Claim Statement Period Start Date is equivalent to the prescription filled date. Required when the "Statement From or To Dates" are not supplied at the service (2110 loop) level. If not required by this implementation guide, may be provided at senders discretion, but cannot be required by the receiver. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM23220250130~ Variants (all may be used) DTM Claim Received Date DTM Coverage Expiration Date Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 232 Claim Statement Period Start If the claim statement period start date is conveyed without a subsequent claim statement period end date, the end date is assumed to be the same as the start date. This date or code 233 is required when service level dates are not provided in the remittance advice. 233 Claim Statement Period End If a claim statement period end date is conveyed without a claim statement period start date, then the start date is assumed to be different from the end date but not conveyed at the payer's discretion. See the note on code 232. DTM-02 373 Claim Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 80/127 PER 0600 Detail > Header Number Loop > Claim Payment Information Loop > PER Claim Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when there is a claim specific communications contact. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800)555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number. Example PERCXXXXTEXXXXXEXXXXXXXEXXX~ If either Communication Number Qualifier (PER-05) or Claim Contact Communications Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number Extension (PER-08) is present, then the other is required Max use 2 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Claim Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 81/127 EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Communication Number Extension Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 82/127 AMT 0620 Detail > Header Number Loop > Claim Payment Information Loop > AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send/receive one AMT for each applicable non-zero value. Do not report any zero values. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTD800~ Max use 13 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount AU Coverage Amount Use this monetary amount to report the total covered charges. This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan. This excludes charges considered not covered (i.e. per day television or telephone charges) but includes reductions to payments of covered services (i.e. reductions for amounts over fee schedule and patient deductibles). 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 Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 83/127 Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 84/127 QTY 0640 Detail > Header Number Loop > Claim Payment Information Loop > QTY Claim Supplemental Information Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send one QTY for each non-zero value. Do not report any zero values. Required when the value of a specific quantity identified by the QTY01 qualifier is non- zero. If not required by this implementation guide, do not send. Example QTYPS000000000~ Max use 14 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity CA Covered - Actual CD Co-insured - Actual LA Life-time Reserve - Actual 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 Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 85/127 2110 Service Payment Information Loop Max 999 Optional SVC 0700 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > SVC Service Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO7825~). See section 1.10.2.4.1 for additional information. See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information. Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send. Example SVCER>XX>XX>XX>XX>XX00000000000000000000XX00 0IV>XXX>XX>XX>XX>XX>XXX00000000000000~ Max use 1 Required SVC-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132). Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7.	Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
> Claim Payment Information Loop > QTY Claim Supplemental Information Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send one QTY for each non-zero value. Do not report any zero values. Required when the value of a specific quantity identified by the QTY01 qualifier is non- zero. If not required by this implementation guide, do not send. Example QTYPS000000000~ Max use 14 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity CA Covered - Actual CD Co-insured - Actual LA Life-time Reserve - Actual 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 Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 85/127 2110 Service Payment Information Loop Max 999 Optional SVC 0700 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > SVC Service Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO7825~). See section 1.10.2.4.1 for additional information. See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information. Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send. Example SVCER>XX>XX>XX>XX>XX00000000000000000000XX00 0IV>XXX>XX>XX>XX>XX>XXX00000000000000~ Max use 1 Required SVC-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132). Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7. 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 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 86/127 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 Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 87/127 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. SVC-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC02 is the submitted service charge. Usage notes Use this monetary amount for the submitted service charge amount. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. SVC-03 782 Line Item Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC03 is the amount paid this service. Usage notes Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. See 1.10.2.1, Balancing, for additional information. SVC-04 234 National Uniform Billing Committee Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service SVC04 is the National Uniform Billing Committee Revenue Code. Usage notes If the original claim and adjudication only referenced an NUBC revenue code, that is supplied in SVC01 and this element is not used. SVC-05 380 Units of Service Paid Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC05 is the paid units of service. Usage notes If not present, the value is assumed to be one. SVC-06 C003 Composite Medical Procedure Identifier Max use 1 Optional 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 88/127 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 Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7. 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 Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 89/127 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVC-07 380 Original Units of Service Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC07 is the original submitted units of service. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 90/127 DTM 0800 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > DTM Service Date To specify pertinent dates and times Usage notes Dates at the service line level apply only to the service line where they appear. If used for inpatient claims and no service date was provided on the claim then report the through date from the claim level. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. Required when claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. For retail pharmacy claims, the service date is equivalent to the prescription filled date. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being	Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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 Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 89/127 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVC-07 380 Original Units of Service Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC07 is the original submitted units of service. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 90/127 DTM 0800 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > DTM Service Date To specify pertinent dates and times Usage notes Dates at the service line level apply only to the service line where they appear. If used for inpatient claims and no service date was provided on the claim then report the through date from the claim level. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. Required when claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. For retail pharmacy claims, the service date is equivalent to the prescription filled date. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM15020250130~ Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 150 Service Period Start This qualifier is required for reporting the beginning of multi-day services. If not required by this implementation guide, do not send. 151 Service Period End This qualifier is required for reporting the end of multi-day services. If not required by this implementation guide, do not send. 472 Service This qualifier is required to indicate a single day service. If not required by this implementation guide, do not send. DTM-02 373 Service Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 91/127 CAS 0900 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > CAS Service Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes An example of this level of CAS is the reduction for the part of the service charge that exceeds the usual and customary charge for the service. See sections 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02). If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CASOAXXXX000000000000000000XXXX000000000000 0000000000000X0000000000000000000XXXXX00000 0000000000000000000XXX0000000000000000000XX X0000*000000~ If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS- 07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 92/127 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer/payee agreement or a regulatory requirement has resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. 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 Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03 and CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 93/127 A positive number decreases paid units, and a negative value increases paid units. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 94/127 CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 95/127 Usage notes See CAS02. CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 96/127 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF HealthCare Policy Identification To specify identifying information Usage notes Required when; The payment is adjusted in accordance with the Payer's published Healthcare Policy Code list and A Claim Adjustment Reason Code identified by the notation, "refer to 835 Healthcare Policy identification segment", in the Claim Adjustment Reason Code List is present in a related CAS segment and The payer has a published enumerated healthcare policy code list available to healthcare providers via an un-secure public website and The payer	Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
CAS02. CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 94/127 CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 95/127 Usage notes See CAS02. CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 96/127 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF HealthCare Policy Identification To specify identifying information Usage notes Required when; The payment is adjusted in accordance with the Payer's published Healthcare Policy Code list and A Claim Adjustment Reason Code identified by the notation, "refer to 835 Healthcare Policy identification segment", in the Claim Adjustment Reason Code List is present in a related CAS segment and The payer has a published enumerated healthcare policy code list available to healthcare providers via an un-secure public website and The payer wishes to supply this policy detail to reduce provider inquiries. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Healthcare Policy - A clinical/statutory rule use to determine claim adjudication that cannot be explained by the sole use of a claim adjustment reason code in the CAS segment and Remittance Advise Remark code when appropriate. The term Healthcare Policy is intended to include Medical Review Policy, Dental Policy Review, Property and Casualty Policies, Workers Comp Policies and Pharmacy Policies for example Medicare LMRP's.( Local Medicare Review policies) and NCD (National Coverage Determinations). This policy segment must not be used to provide a proprietary explanation code or reason for adjustment. Supply the Healthcare policy identifier in REF02 as provided by the payer's published Healthcare policy code list. This policy code will be used to explain the policy used to process the claim which resulted in the adjusted payment. 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 REF0KX~ Variants (all may be used) REF Line Item Control Number REF Rendering Provider Information REF Service Identification Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0K Policy Form Identifying Number REF-02 127 Healthcare Policy Identification Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 97/127 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Line Item Control Number To specify identifying information Usage notes This is the Line Item Control Number submitted in the 837, which is utilized by the provider for tracking purposes. See section 1.10.2.11 and 1.10.2.14.1 for additional information on usage with split claims or services. Note - the value in REF02 can include alpha characters. Required when a Line Item Control Number was received on the original claim or when claim or service line splitting has occurred. If not required by this implementation guide, do not send. Example REF6RXXX~ Variants (all may be used) REF HealthCare Policy Identification REF Rendering Provider Information REF Service Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 98/127 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Rendering Provider Information To specify identifying information Usage notes Required when the rendering provider for this service is different than the rendering provider applicable at the claim level. If not required by this implementation guide, do not send. Example REF1HX~ Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Service Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 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. TJ Federal Taxpayer's Identification Number REF-02 127 Rendering Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 99/127 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Service Identification To specify identifying information Usage notes Required when related service specific reference identifiers were used in the process of adjudicating this service. If not required by this implementation guide, do not send. Example REFG1X~ Variants (all may be used) REF HealthCare Policy Identification REF Line Item Control Number REF Rendering Provider Information Max use 8 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1S Ambulatory Patient Group (APG) Number APC Ambulatory Payment Classification 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 Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 100/127 AMT 1100 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > AMT Service Supplemental Amount To indicate the total monetary amount Usage notes This segment is used to convey information only. It is not part of the financial balancing of the 835. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTZL00~ Max use 9 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount B6 Allowed - Actual Allowed amount is the amount the payer deems payable prior to considering patient responsibility. KH Deduction Amount Late Filing Reduction 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 Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 101/127 QTY 1200 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > QTY Service Supplemental Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Required when new Federal Medicare or Medicaid mandates require Quantity counts and value of specific quantities identified in the QTY01 qualifier are non-zero. If not required by this implementation guide, do not send. Example QTYZK0~ Max use 6 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Service Supplemental Quantity Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 102/127 2110 Service Payment Information Loop end 2100 Claim Payment Information Loop end 2000 Header Number Loop end Detail end LQ 1300 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > LQ Health Care Remark Codes To identify standard industry codes Usage notes Use this segment to provide informational remarks only. This segment has no impact on the actual payment. Changes in claim payment amounts are provided in the CAS segments. Required when remark codes or NCPDP Reject/Payment codes are necessary for the provider to fully understand the adjudication message for a given service line. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example LQRXXXXX~ Max use 99 Optional LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list HE Claim Payment Remark Codes RX National Council for Prescription Drug Programs Reject/Payment Codes LQ-02 1271 Remark Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1)	Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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 Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 101/127 QTY 1200 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > QTY Service Supplemental Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Required when new Federal Medicare or Medicaid mandates require Quantity counts and value of specific quantities identified in the QTY01 qualifier are non-zero. If not required by this implementation guide, do not send. Example QTYZK0~ Max use 6 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Service Supplemental Quantity Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 102/127 2110 Service Payment Information Loop end 2100 Claim Payment Information Loop end 2000 Header Number Loop end Detail end LQ 1300 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > LQ Health Care Remark Codes To identify standard industry codes Usage notes Use this segment to provide informational remarks only. This segment has no impact on the actual payment. Changes in claim payment amounts are provided in the CAS segments. Required when remark codes or NCPDP Reject/Payment codes are necessary for the provider to fully understand the adjudication message for a given service line. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example LQRXXXXX~ Max use 99 Optional LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list HE Claim Payment Remark Codes RX National Council for Prescription Drug Programs Reject/Payment Codes LQ-02 1271 Remark Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 103/127 Summary PLB 0100 Summary > PLB Provider Adjustment To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service Usage notes These adjustments can either decrease the payment (a positive number) or increase the payment (a negative number). Zero dollar adjustments are not allowed. Some examples of PLB adjustments are a Periodic Interim Payment (loans and loan repayment) or a capitation payment. Multiple adjustments can be placed in one PLB segment, grouped by the provider identified in PLB01 and the period identified in PLB02. Although the PLB reference numbers are not standardized, refer to 1.10.2.9 (Interest and Prompt Payment Discounts), 1.10.2.10 (Capitation and Related Payments or Adjustments), 1.10.2.12 (Balance Forward Processing), 1.10.2.16 (Post Payment Recovery) and 1.10.2.17 (Claim Overpayment Recovery) for code suggestions and usage guidelines. The codes and notations under PLB03 and its components apply equally to PLB05, 07, 09, 11 and 13. Required when reporting adjustments to the actual payment that are NOT specific to a particular claim or service. If not required by this implementation guide, do not send. Example PLBXXX20250130LE>XXXXX0000000000XX>XX0000 0XX>X0000000000000XX>X0000000000XX>XXXX0X X>X000~ If either Adjustment Identifier (PLB-05) or Provider Adjustment Amount (PLB-06) is present, then the other is required If either Adjustment Identifier (PLB-07) or Provider Adjustment Amount (PLB-08) is present, then the other is required If either Adjustment Identifier (PLB-09) or Provider Adjustment Amount (PLB-10) is present, then the other is required If either Adjustment Identifier (PLB-11) or Provider Adjustment Amount (PLB-12) is present, then the other is required If either Adjustment Identifier (PLB-13) or Provider Adjustment Amount (PLB-14) is present, then the other is required Max use >1 Optional PLB-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB01 is the provider number assigned by the payer. Usage notes When the National Provider Identifier (NPI) is mandated and the provider is a covered health care provider under that mandate, this must be the NPI assigned to the provider. Until the NPI is mandated, this is the provider identifier as assigned by the payer. PLB-02 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 104/127 year PLB02 is the last day of the provider's fiscal year. Usage notes This is the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known by the payer, use December 31st of the current year. PLB-03 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB03 is the adjustment information as defined by the payer. Max use 1 Required C042-01 426 Adjustment Reason Code Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment 50 Late Charge This is the Late Claim Filing Penalty or Medicare Late Cost Report Penalty. 51 Interest Penalty Charge This is the interest assessment for late filing. 72 Authorized Return This is the provider refund adjustment. This adjustment acknowledges a refund received from a provider for previous overpayment. PLB03-2 must always contain an identifying reference number when the value is used. PLB04 must contain a negative value. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. 90 Early Payment Allowance 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. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 105/127 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 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 106/127 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 Min 1 Max 50 String (AN) Optional 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,	Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 106/127 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 Min 1 Max 50 String (AN) Optional 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 Min 1 Max 15 Decimal number (R) Required 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 Max use 1 Optional 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 107/127 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 Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-06 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 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. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-08 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB08 is the adjustment amount. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 108/127 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. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-10 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 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. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 109/127 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-12 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 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. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-14 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB14 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 110/127 Summary end SE 0200 Summary > SE Transaction Set Trailer To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments) Example SE0000000001~ Max use 1 Required SE-01 96 Transaction Segment Count Min 1 Max 10 Numeric (N0) Required Total number of segments included in a transaction set including ST and SE segments SE-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required 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. 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 111/127 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE000000~ Max use 1 Required GE-01 97 Number of Transaction Sets Included Min 1 Max 6 Numeric (N0) Required 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 Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 112/127 IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA00000000000~ Max use 1 Required IEA-01 I16 Number of Included Functional Groups Min 1 Max 5 Numeric (N0) Required A count of the number of functional groups included in an interchange IEA-02 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 113/127 EDI Samples Example 1: Dollars and Data Sent Separately ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD2019082712345678012345678X005010X221A1~ ST835112233~ BPRI1100CACHCCP01888999777DA246810121935665544*01111333555DA14444420190316~ TRN1717006665551935665544~ DTM40520190314~ N1PRRUSHMORE LIFE~ N310 SOUTH AVENUET~ N4RAPID CITYSD55111~ PERBLJOHN WAYNETE8005551212EX123~ N1PEACME MEDICAL CENTERXX5544667733~ REF0B777667755~ LX1~ CLP555455544418005003001294060555410000111~ NM1QC1BUDDWILLIAM***MI33344555510~ AMTAU800~ SVCHC>99211800500~ DTM47220190301~ CASPR1300~ AMTB6800~ CLP876543211211200600600129407779923000111~ NM1QC1SETTLESUSAN**MI44455666610~ AMTAU1200~ SVCHC>935551200600~ DTM47220190310~ CASPR1600~ AMTB61200~ SE26112233~ GE1012345678~ IEA1191511902~ 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 114/127 Example 2: Multiple Claims Single Check ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83535681~ BPRI810.8CCHK***********20190331~ TRN1123451512345678~ REFEVXYZ CLEARINGHOUSE~ N1PRDENTAL OF ABC~ N3225 MAIN STREET~ N4CENTERVILLEPA17111~ PERBLJANE DOETE9005555555~ N1PEBAN DDS LLCXX9999947036~ REF0B212121212~ LX1~ CLP7722337122613212119932404007801111~ NM1QC1DOESANDY***MISJD11112~ NM1821BANERIN***XX1811901945~ AMTAU132~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D02202514~ DTM47220190324~ CASCO4511~ AMTB614~ SVCAD>D02302210~ DTM47220190324~ CASCO4512~ AMTB610~ SVCAD>D02746034~ DTM47220190324~ CASCO4526~ AMTB634~ SVCAD>D11107349~ DTM47220190324~ CASCO4524~ AMTB649~ CLP7722337111974*12119932404007801111~ NM1QC1DOESALLY***MISJD11111~ NM1IL1DOEJOHN***MISJD11111~ NM1821BANERIN***XX1811901945~ AMTAU74~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D11107349~ DTM47220190324~ CASCO4524~ AMTB649~ CLP772233712261082412119932404007801111~ NM1QC1SMITHSALLY**MISJD11113~ NM1821BANERIN***XX1811901945~ AMTAU132~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 115/127 AMTB625~ SVCAD>D0220250~ DTM47220190324~ CASPR314~ CASCO4511~ AMTB614~ SVCAD>D0230220~ DTM47220190324~ CASPR310~ CASCO4512~ AMTB610~ SVCAD>D02746034~ DTM47220190324~ CASCO4526~ AMTB634~ SVCAD>D11107349~ DTM47220190324~ CASCO4524~ AMTB649~ CLP7722337111451490212119932404007801111~ NM1QC1SMITHSAM**MISJD11116~ NM1821BANERIN***XX1811901945~ AMTAU14~ SVCAD>D02202514~ DTM47220190324~ CASCO4511~ AMTB614~ SVCAD>D27909400~ DTM47220190324~ CASPR3756~ CASCO45184~ SVCAD>D29501800~ DTM47220190324~ CASPR3146~ CASCO4534~ CLP7722337134816.844.212119932404007801111~ NM1QC1JONESSAM**MISJD11122~ NM1821BANERIN***XX1811901945~ AMTAU28~ SVCAD>D43421250~ DTM47220190313~ CASCO45125~ SVCAD>D4381430~ DTM47220190313~ CASPR333~ CASCO4510~ SVCAD>D295018016.8~ DTM47220190313~ CASPR311.2~ CASCO45152~ AMTB628~ CLP77223371226132*12119932404007801111~ NM1QC1JONESSALLY***MISJD11133~ NM1821BANERIN***XX1811901945~ AMTAU132~ SVCAD>D01204625~ DTM47220190321~ CASCO4521~ AMTB625~ SVCAD>D02202514~ 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 116/127 DTM47220190321~ CASCO4511~ AMTB614~ SVCAD>D02302210~ DTM47220190321~ CASCO4512~ AMTB610~ SVCAD>D02746034~ DTM47220190321~ CASCO4526~ AMTB634~ SVCAD>D11107349~ DTM47220190321~ CASCO4524~ AMTB649~ CLP77223371179108*12119932404007801111~ NM1QC1DOESAM***MISJD99999~ NM1821BANERIN***XX1811901945~ AMTAU108~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D02746034~ DTM47220190324~ CASCO4526~ AMTB634~ SVCAD>D11107349~ DTM47220190324~ CASCO4524~ AMTB649~ CLP7722337112982*12119932404007801111~ NM1QC1DOESUE***MISJD88888~ NM1821BANERIN***XX1811901945~ AMTAU82~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D11205437~ DTM47220190324~ CASCO4517~ AMTB637~ SVCAD>D12082920~ DTM47220190324~ CASCO459~ AMTB620~ CLP77223371221144*12119932404007801111~ NM1QC1DOEDONNA***MISJD77777~ NM1821BANERIN***XX1811901945~ AMTAU144~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D03309262~ DTM47220190324~ CASCO4530~ AMTB662~ SVCAD>D11205437~ 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 117/127 DTM47220190324~ CASCO4517~ AMTB637~ SVCAD>D12082920~ DTM472*20190324~	Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 111/127 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE000000~ Max use 1 Required GE-01 97 Number of Transaction Sets Included Min 1 Max 6 Numeric (N0) Required 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 Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 112/127 IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA00000000000~ Max use 1 Required IEA-01 I16 Number of Included Functional Groups Min 1 Max 5 Numeric (N0) Required A count of the number of functional groups included in an interchange IEA-02 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 113/127 EDI Samples Example 1: Dollars and Data Sent Separately ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD2019082712345678012345678X005010X221A1~ ST835112233~ BPRI1100CACHCCP01888999777DA246810121935665544*01111333555DA14444420190316~ TRN1717006665551935665544~ DTM40520190314~ N1PRRUSHMORE LIFE~ N310 SOUTH AVENUET~ N4RAPID CITYSD55111~ PERBLJOHN WAYNETE8005551212EX123~ N1PEACME MEDICAL CENTERXX5544667733~ REF0B777667755~ LX1~ CLP555455544418005003001294060555410000111~ NM1QC1BUDDWILLIAM***MI33344555510~ AMTAU800~ SVCHC>99211800500~ DTM47220190301~ CASPR1300~ AMTB6800~ CLP876543211211200600600129407779923000111~ NM1QC1SETTLESUSAN**MI44455666610~ AMTAU1200~ SVCHC>935551200600~ DTM47220190310~ CASPR1600~ AMTB61200~ SE26112233~ GE1012345678~ IEA1191511902~ 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 114/127 Example 2: Multiple Claims Single Check ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83535681~ BPRI810.8CCHK***********20190331~ TRN1123451512345678~ REFEVXYZ CLEARINGHOUSE~ N1PRDENTAL OF ABC~ N3225 MAIN STREET~ N4CENTERVILLEPA17111~ PERBLJANE DOETE9005555555~ N1PEBAN DDS LLCXX9999947036~ REF0B212121212~ LX1~ CLP7722337122613212119932404007801111~ NM1QC1DOESANDY***MISJD11112~ NM1821BANERIN***XX1811901945~ AMTAU132~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D02202514~ DTM47220190324~ CASCO4511~ AMTB614~ SVCAD>D02302210~ DTM47220190324~ CASCO4512~ AMTB610~ SVCAD>D02746034~ DTM47220190324~ CASCO4526~ AMTB634~ SVCAD>D11107349~ DTM47220190324~ CASCO4524~ AMTB649~ CLP7722337111974*12119932404007801111~ NM1QC1DOESALLY***MISJD11111~ NM1IL1DOEJOHN***MISJD11111~ NM1821BANERIN***XX1811901945~ AMTAU74~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D11107349~ DTM47220190324~ CASCO4524~ AMTB649~ CLP772233712261082412119932404007801111~ NM1QC1SMITHSALLY**MISJD11113~ NM1821BANERIN***XX1811901945~ AMTAU132~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 115/127 AMTB625~ SVCAD>D0220250~ DTM47220190324~ CASPR314~ CASCO4511~ AMTB614~ SVCAD>D0230220~ DTM47220190324~ CASPR310~ CASCO4512~ AMTB610~ SVCAD>D02746034~ DTM47220190324~ CASCO4526~ AMTB634~ SVCAD>D11107349~ DTM47220190324~ CASCO4524~ AMTB649~ CLP7722337111451490212119932404007801111~ NM1QC1SMITHSAM**MISJD11116~ NM1821BANERIN***XX1811901945~ AMTAU14~ SVCAD>D02202514~ DTM47220190324~ CASCO4511~ AMTB614~ SVCAD>D27909400~ DTM47220190324~ CASPR3756~ CASCO45184~ SVCAD>D29501800~ DTM47220190324~ CASPR3146~ CASCO4534~ CLP7722337134816.844.212119932404007801111~ NM1QC1JONESSAM**MISJD11122~ NM1821BANERIN***XX1811901945~ AMTAU28~ SVCAD>D43421250~ DTM47220190313~ CASCO45125~ SVCAD>D4381430~ DTM47220190313~ CASPR333~ CASCO4510~ SVCAD>D295018016.8~ DTM47220190313~ CASPR311.2~ CASCO45152~ AMTB628~ CLP77223371226132*12119932404007801111~ NM1QC1JONESSALLY***MISJD11133~ NM1821BANERIN***XX1811901945~ AMTAU132~ SVCAD>D01204625~ DTM47220190321~ CASCO4521~ AMTB625~ SVCAD>D02202514~ 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 116/127 DTM47220190321~ CASCO4511~ AMTB614~ SVCAD>D02302210~ DTM47220190321~ CASCO4512~ AMTB610~ SVCAD>D02746034~ DTM47220190321~ CASCO4526~ AMTB634~ SVCAD>D11107349~ DTM47220190321~ CASCO4524~ AMTB649~ CLP77223371179108*12119932404007801111~ NM1QC1DOESAM***MISJD99999~ NM1821BANERIN***XX1811901945~ AMTAU108~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D02746034~ DTM47220190324~ CASCO4526~ AMTB634~ SVCAD>D11107349~ DTM47220190324~ CASCO4524~ AMTB649~ CLP7722337112982*12119932404007801111~ NM1QC1DOESUE***MISJD88888~ NM1821BANERIN***XX1811901945~ AMTAU82~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D11205437~ DTM47220190324~ CASCO4517~ AMTB637~ SVCAD>D12082920~ DTM47220190324~ CASCO459~ AMTB620~ CLP77223371221144*12119932404007801111~ NM1QC1DOEDONNA***MISJD77777~ NM1821BANERIN***XX1811901945~ AMTAU144~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D03309262~ DTM47220190324~ CASCO4530~ AMTB662~ SVCAD>D11205437~ 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 117/127 DTM47220190324~ CASCO4517~ AMTB637~ SVCAD>D12082920~ DTM47220190324~ CASCO459~ AMTB620~ SE18335681~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 118/127 Example 3: Claim Specific Negotiated Discount ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83535681~ BPRI132CCHK***********20190331~ TRN1123451512345678~ REFEVCLEARINGHOUSE~ N1PRDELTA DENTAL OF ABC~ N3225 MAIN STREET~ N4CENTERVILLEPA17111~ PERBLJANE DOETE9005555555~ N1PEBAN DDS LLCXV999994703~ LX1~ CLP7722337122613212119932404007801~ NM1QC1DOESALLY***MISJD11111~ NM1821BANERIN***XX1811901945~ AMTAU132~ SVCAD>D01204625~ DTM47220190324~ CASCO13121~ AMTB625~ SVCAD>D02202514~ DTM47220190324~ CASCO13111~ AMTB614~ SVCAD>D02302210~ DTM47220190324~ CASCO13112~ AMTB610~ SVCAD>D02746034~ DTM47220190324~ CASCO13126~ AMTB634~ SVCAD>D11107349~ DTM47220190324~ CASCO13124~ AMTB649~ SE3535681~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 119/127 Example 4: Claim Adjustment Reason Code 45 ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI80.00CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REF0B123456789~ LX1~ CLPPATACCT140080MCCLAIMNUMBER111~ NM1QC1DOEJOHNN*MIABC123456789~ REF1L12345F~ DTM05020190209~ PERCXG CUSTOMER SERVICE DEPARTMENTTE8004074627~ AMTAU150~ SVCHC>99213150801~ DTM47220190101~ CASCO4570~ AMTB680~ SVCHC>8500310001~ DTM47220190101~ CASCO204100~ SVCHC>3641515001~ DTM47220190101~ CASCO97150~ SE3310060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 120/127 Example 5a: Line Service Tax impacting payment only ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI11.06CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REF0B123456789~ LX1~ CLPPCN136.2011.0612CLAIMNUMB111~ NM1QC1LASTFIRSTJ*MI123456789~ NM1821*****XX1447481825~ MOA**N25~ REF1L102345~ REFEA065789~ DTM05020170113~ AMTAU36.20~ SVCHC>9921426.23.06~ DTM47220170109~ CASCO4523.2137-.06~ REF6RB1~ AMTB63~ SVCHC>36415108~ DTM47220170109~ CASCO452~ REF6RB2~ AMTB68~ SE3510060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 121/127 Example 5b: Line Service Bonuses impacting payment only ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI12.00CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REF0B123456789~ LX1~ CLPPCN125121012CLAIMNUMB111~ NM1QC1LASTFIRSTJ*MI123456789~ NM1821*****XX1447481825~ MOA**N25~ REF1L102345~ REFEA065789~ DTM05020170113~ AMTAU25~ SVCHC>992142512~ DTM47220170109~ CASCO455161-2~ CASPR310~ REF6R123~ AMTB620~ SE3110060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 122/127 Example 5c: Line Service Penalty impacting payment only ISA00* 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI8.00CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REF0B123456789~ LX1~ CLPPCN12581012CLAIMNUMB111~ NM1QC1LASTFIRSTJ*MI123456789~ NM1821*****XX1447481825~ MOA**N25~ REF1L102345~ REFEA065789~ DTM05020170113~ AMTAU25~ SVCHC>99214258~ DTM47220170109~ CASCO455B42~ CASPR310~ REF6R123~ AMTB620~ SE3110060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 123/127 Example 6: Not Covered/Not Authorized Inpatient Facility claim days ISA00* 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI8000.00CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REF0B123456789~ LX1~ CLPPATACCT1400008000MCCLAIMNUMBER111~ CASCO197200014530000~ NM1QC1DOEJOHNN*MIABC123456789~ REF1L12345F~ DTM23220190101~ DTM23320190105~ DTM05020190209~ PERCXG CUSTOMER SERVICE DEPARTMENTTE8004001212~ AMTAU38000~ QTYCA4~ SE2710060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 124/127 Example 8a: Claim submitted with incorrect subscriber as patient and incorrect ID ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P\|~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI120.03CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REF0B123456789~ LX1~ CLP04777796TLC7771221155120.03138838888212111~ NM1QC1MASTERSMARVINL*MI80444444403~ NM1IL1CABLEMABEL***MI80444444403~ NM1741MASTERSMARVIN***C80444444401~ NM1821SHELTON MDBLAKE***XX1666666666~ REF1L28~ REFCEHSOAP-LAOA~ DTM23220191114~ DTM23320181114~ DTM05020181119~ AMTAU155~ SVCHC\|99393155120.031~ DTM47220181114~ CASCO4534.97~ REFLU11~ REF6R22261822~ AMTB6120.03~ SE3410060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 125/127 Example 8b: Claim submitted with incorrect subscriber name and ID ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P\|~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI35.06CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REF0B123456789~ LX1~ CLP02333TLC222222111535.0635138333333214111~ NM1QC1KEATONALEXP*MI80000006006~ NM1IL1THOMASJASON***MI80000006006~ NM1741JEROME*C80000006001~ NM1821BLOOD MDRED N***XX1888888886~ REF1L28~ REFCEOAPOS-LAOA~ DTM23220191113~ DTM23320191113~ DTM05020191119~ AMTAU115~ SVCHC\|9921311535.061~ DTM47220191113~ CASCO4544.94~ CASPR335~ REFLU11~ REF6R22261389~ AMTB670.06~ SE3510060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 126/127 Stedi is a registered trademark of Stedi, Inc. 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Example 8c: Claim submitted with for subscriber missing the Middle initial ISA00* 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI2415.25CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REF0B123456789~ LX1~ CLP05444444TLC999999139032415.25138777777782211~ NM1QC1GONZALESSAMMY***MI80455555502~ NM1IL1LAPLANTEFERN***MI80455555502~ NM1741**R~ NM1821GOOD MDROBERT B**XX19999999987~ REF1L28~ REFCEOAPOS-LAOA~ DTM23220191101~ DTM23320191101~ DTM05020191114~ AMTAU3903~ AMTF5150~ SVCHC>5940039032415.251~ DTM47220191101~ CASCO451487.75~ REFLU21~ REF6R22215592~ AMTB62415.25~ SE3510060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 127/127	Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
Stedi maintains this guide based on public documentation from X12 HIPAA. Contact X12 HIPAA for official EDI specifications. To report any errors in this guide, please contact us. X12 835 Health Care Claim Payment/Advice (X221A1) X12 Release 5010 Revised May 3, 2024 Go to Stedi Network 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 View the latest version of this implementation guide as an interactive webpage https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice- x221a1/01GRYB6DS30MGXWBPFZCM3695E POWERED BY Build EDI implementation guides at stedi.com 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 1/128 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 Payer Identification Loop N1 0800 Payer Identification Max use 1 Required N3 1000 Payer Address Max use 1 Required N4 1100 Payer City, State, ZIP Code Max use 1 Required REF 1200 Additional Payer Identification Max use 4 Optional PER 1300 Payer Business Contact Information Max use 1 Optional PER 1300 Payer Technical Contact Information Max use 1 Required PER 1300 Payer WEB Site Max use 1 Optional Payee Identification Loop N1 0800 Payee Identification Max use 1 Required N3 1000 Payee Address Max use 1 Optional N4 1100 Payee City, State, ZIP Code Max use 1 Optional REF 1200 Payee Additional Identification Max use 1 Optional RDM 1400 Remittance Delivery Method Max use 1 Optional 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 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 2/128 Claim Payment Information Loop CLP 0100 Claim Payment Information Max use 1 Required CAS 0200 Claim Adjustment Max use 99 Optional NM1 0300 Patient Name Max use 1 Required NM1 0300 Insured Name Max use 1 Optional NM1 0300 Corrected Patient/Insured Name Max use 1 Optional NM1 0300 Service Provider Name Max use 1 Optional NM1 0300 Crossover Carrier Name Max use 1 Optional NM1 0300 Corrected Priority Payer Name Max use 1 Optional NM1 0300 Other Subscriber Name Max use 1 Optional MIA 0330 Inpatient Adjudication Information Max use 1 Optional MOA 0350 Outpatient Adjudication Information Max use 1 Optional REF 0400 Other Claim Related Identification Max use 5 Optional REF 0400 Rendering Provider Identification Max use 10 Optional DTM 0500 Statement From or To Date Max use 2 Optional DTM 0500 Coverage Expiration Date Max use 1 Optional DTM 0500 Claim Received Date Max use 1 Optional PER 0600 Claim Contact Information Max use 2 Optional AMT 0620 Claim Supplemental Information Max use 13 Optional QTY 0640 Claim Supplemental Information Quantity Max use 14 Optional Service Payment Information Loop SVC 0700 Service Payment Information Max use 1 Required DTM 0800 Service Date Max use 2 Optional CAS 0900 Service Adjustment Max use 99 Optional REF 1000 Service Identification Max use 8 Optional REF 1000 Line Item Control Number Max use 1 Optional REF 1000 Rendering Provider Information Max use 10 Optional REF 1000 HealthCare Policy Identification Max use 5 Optional AMT 1100 Service Supplemental Amount Max use 9 Optional QTY 1200 Service Supplemental Quantity Max use 6 Optional LQ 1300 Health Care Remark Codes Max use 99 Optional 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 3/128 Summary PLB 0100 Provider Adjustment Max use 1 Optional SE 0200 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 4/128 ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange- related control segments Example ISA00 00 XXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXX2501300532^0050100000000 0XX>~ Max use 1 Required ISA-01 I01 Authorization Information Qualifier Identifier (ID) 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 Min 10 Max 10 String (AN) Required 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 Identifier (ID) 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 Min 10 Max 10 String (AN) Required 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 Min 2 Max 2 Identifier (ID) Required 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 Min 15 Max 15 String (AN) Required 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 Min 2 Max 2 Identifier (ID) Required 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 5/128 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 Min 15 Max 15 String (AN) Required 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 YYMMDD format Date (DT) Required Date of the interchange ISA-10 I09 Interchange Time HHMM format Time (TM) Required Time of the interchange ISA-11 I65 Repetition Separator Min 1 Max 1 String (AN) Required 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 Identifier (ID) 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 Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender ISA-14 I13 Acknowledgment Requested Min 1 Max 1 Identifier (ID) Required 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 Min 1 Max 1 Identifier (ID) Required Code indicating whether data enclosed by this interchange envelope is test, production or information I Information 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 6/128 P Production Data T Test Data ISA-16 I15 Component Element Separator Min 1 Max 1 String (AN) Required 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 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 7/128 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GSHPXXXXXXXXXXXXX20250130083600000X005010 X221A1~ Max use 1 Required GS-01 479 Functional Identifier Code Identifier (ID) Required Code identifying a group of application related transaction sets HP Health Care Claim Payment/Advice (835) GS-02 142 Application Sender's Code Min 2 Max 15 String (AN) Required Code identifying party sending transmission; codes agreed to by trading partners GS-03 124 Application Receiver's Code Min 2 Max 15 String (AN) Required Code identifying party receiving transmission; codes agreed to by trading partners GS-04 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year GS-05 337 Time HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time (TM) Required 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 Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required 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 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 8/128 GS-08 480 Version / Release / Industry Identifier Code String (AN) 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 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 9/128 Heading ST 0100 Heading > ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST8350001~ Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) 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 Min 4 Max 9 Numeric (N) Required 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. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 10/128 BPR 0200 Heading > BPR Financial Information To indicate the beginning of a Payment Order/Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and/or information from payer to payee to occur 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 BPRU000000CNONCCP04XXXXXXXXDAXXXXXXXXXX XXXXXXXXXXXXXXX01XXXXXXXDAX20250130~ If	X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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 Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required 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 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 8/128 GS-08 480 Version / Release / Industry Identifier Code String (AN) 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 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 9/128 Heading ST 0100 Heading > ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST8350001~ Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) 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 Min 4 Max 9 Numeric (N) Required 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. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 10/128 BPR 0200 Heading > BPR Financial Information To indicate the beginning of a Payment Order/Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and/or information from payer to payee to occur 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 BPRU000000CNONCCP04XXXXXXXXDAXXXXXXXXXX XXXXXXXXXXXXXXX01XXXXXXXDAX20250130~ 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 Max use 1 Required BPR-01 305 Transaction Handling Code Identifier (ID) 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. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 11/128 BPR-02 782 Total Actual Provider Payment Amount Min 1 Max 15 Decimal number (R) Required 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 Identifier (ID) 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 Identifier (ID) 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 Identifier (ID) Optional Code identifying the payment format to be used CCP Cash Concentration/Disbursement plus Addenda (CCD+) (ACH) 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 12/128 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 Identifier (ID) 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 Min 3 Max 12 String (AN) Optional 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 Identifier (ID) 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 Min 1 Max 35 String (AN) Optional 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 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 13/128 Use this number for the originator's account number at the financial institution. BPR-10 509 Payer Identifier Min 10 Max 10 String (AN) Optional 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 Min 9 Max 9 String (AN) Optional 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 Identifier (ID) 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 Min 3 Max 12 String (AN) Optional 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 Identifier (ID) 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. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 14/128 DA Demand Deposit SG Savings BPR-15 508 Receiver or Provider Account Number Min 1 Max 35 String (AN) Optional 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 CCYYMMDD format Date (DT) Required 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	X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
notes Use this code to identify the type of account in BPR09. DA Demand Deposit BPR-09 508 Sender Bank Account Number Min 1 Max 35 String (AN) Optional 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 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 13/128 Use this number for the originator's account number at the financial institution. BPR-10 509 Payer Identifier Min 10 Max 10 String (AN) Optional 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 Min 9 Max 9 String (AN) Optional 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 Identifier (ID) 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 Min 3 Max 12 String (AN) Optional 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 Identifier (ID) 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. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 14/128 DA Demand Deposit SG Savings BPR-15 508 Receiver or Provider Account Number Min 1 Max 35 String (AN) Optional 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 CCYYMMDD format Date (DT) Required 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. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 15/128 TRN 0400 Heading > TRN Reassociation Trace Number 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 TRN1XXXXXXXXXXXXXXX~ Max use 1 Required TRN-01 481 Trace Type Code Identifier (ID) Required Code identifying which transaction is being referenced 1 Current Transaction Trace Numbers TRN-02 127 Check or EFT Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 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 Min 10 Max 10 String (AN) Required 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 Min 1 Max 50 String (AN) Optional 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 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 16/128 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. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 17/128 CUR 0500 Heading > CUR Foreign Currency Information 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 CURPRXXX~ Max use 1 Optional CUR-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer CUR-02 100 Currency Code Min 3 Max 3 Identifier (ID) Required Code (Standard ISO) for country in whose currency the charges are specified Usage notes This is the currency code for the payment currency. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 18/128 REF 0600 Heading > REF Receiver Identification 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 REFEVX~ Variants (all may be used) REF Version Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EV Receiver Identification Number REF-02 127 Receiver Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 19/128 REF 0600 Heading > REF Version Identification 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 REFF2XXXXXX~ Variants (all may be used) REF Receiver Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F2 Version Code - Local REF-02 127 Version Identification Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 20/128 DTM 0700 Heading > DTM Production Date 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 DTM40520250130~ Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 405 Production DTM-02 373 Production Date CCYYMMDD format Date (DT) Required 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. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 21/128 1000A Payer Identification Loop Max 1 Required Variants (all may be used) Payee Identification Loop N1 0800 Heading > Payer Identification Loop > N1 Payer Identification 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 N1PRXXVXX~ If either Identification Code Qualifier (N1-03) or Payer Identifier (N1-04) is present, then the other is required Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer N1-02 93 Payer Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) 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 Min 2 Max 80 String (AN) Optional 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. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 22/128 N3 1000 Heading > Payer Identification Loop > N3 Payer Address To specify the location of the named party Example N3XXXX~ Max use 1 Required N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 23/128 N4 1100 Heading > Payer Identification Loop > N4 Payer City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXX~ 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 Max use 1 Required N4-01 19 Payer City Name Min 2 Max 30 String (AN) Required 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 Min 2 Max 2 Identifier (ID) Optional 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 Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the	X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
calendar year Usage notes Report the end date for the adjudication production cycle for claims included in this 835. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 21/128 1000A Payer Identification Loop Max 1 Required Variants (all may be used) Payee Identification Loop N1 0800 Heading > Payer Identification Loop > N1 Payer Identification 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 N1PRXXVXX~ If either Identification Code Qualifier (N1-03) or Payer Identifier (N1-04) is present, then the other is required Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer N1-02 93 Payer Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) 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 Min 2 Max 80 String (AN) Optional 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. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 22/128 N3 1000 Heading > Payer Identification Loop > N3 Payer Address To specify the location of the named party Example N3XXXX~ Max use 1 Required N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 23/128 N4 1100 Heading > Payer Identification Loop > N4 Payer City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXX~ 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 Max use 1 Required N4-01 19 Payer City Name Min 2 Max 30 String (AN) Required 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 Min 2 Max 2 Identifier (ID) Optional 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 Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 24/128 REF 1200 Heading > Payer Identification Loop > REF Additional Payer Identification 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 REF2UXXXX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) 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 Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 25/128 PER 1300 Heading > Payer Identification Loop > PER Payer Business Contact Information 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 PERCXXXXXXEMXXXEXXXXXXEXXXXX~ Variants (all may be used) PER Payer Technical Contact Information PER Payer WEB Site 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 Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Payer Contact Name Min 1 Max 60 String (AN) Optional 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 Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 26/128 PER-04 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail 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 Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 27/128 PER 1300 Heading > Payer Identification Loop > PER Payer Technical Contact Information 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 PERBLXTEXTEXXXEMX~ Variants (all may be used) PER Payer Business Contact Information PER Payer WEB Site 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 Max use >1 Required PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named BL Technical Department PER-02 93 Payer Technical Contact Name Min 1 Max 60 String (AN) Optional 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 Identifier (ID) 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 Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 28/128 PER-05 365 Communication Number Qualifier Identifier (ID) 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 Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number 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 Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 29/128 1000A Payer Identification Loop end PER 1300 Heading > Payer Identification Loop > PER Payer WEB Site 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 PERICURXXXX~ Variants (all may be used) PER Payer Business Contact Information PER Payer Technical Contact Information Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number UR Uniform Resource Locator (URL) PER-04 364 Communication Number Min 1 Max 256 String (AN) Required 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. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 30/128 1000B Payee Identification Loop Max 1 Required Variants (all may be used) Payer Identification Loop N1 0800 Heading > Payee Identification Loop > N1 Payee Identification 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 N1PEXFIXXXXXXX~ Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PE Payee N1-02 93 Payee Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) 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	X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
for the payer entity. PER-04 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 28/128 PER-05 365 Communication Number Qualifier Identifier (ID) 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 Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number 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 Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 29/128 1000A Payer Identification Loop end PER 1300 Heading > Payer Identification Loop > PER Payer WEB Site 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 PERICURXXXX~ Variants (all may be used) PER Payer Business Contact Information PER Payer Technical Contact Information Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number UR Uniform Resource Locator (URL) PER-04 364 Communication Number Min 1 Max 256 String (AN) Required 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. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 30/128 1000B Payee Identification Loop Max 1 Required Variants (all may be used) Payer Identification Loop N1 0800 Heading > Payee Identification Loop > N1 Payee Identification 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 N1PEXFIXXXXXXX~ Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PE Payee N1-02 93 Payee Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) 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 Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 31/128 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. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 32/128 N3 1000 Heading > Payee Identification Loop > N3 Payee Address 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 N3XXXXXXX~ Max use 1 Optional N3-01 166 Payee Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payee Address Line Min 1 Max 55 String (AN) Optional Address information 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 33/128 N4 1100 Heading > Payee Identification Loop > N4 Payee City, State, ZIP Code 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 N4XXXXXXXXXXXXXXXXXX~ 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 Max use 1 Optional N4-01 19 Payee City Name Min 2 Max 30 String (AN) Required 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 Min 2 Max 2 Identifier (ID) Optional 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 Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 34/128 REF 1200 Heading > Payee Identification Loop > REF Payee Additional Identification 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 REFD3XXXXX~ Max use >1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) 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 Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 35/128 RDM 1400 Heading > Payee Identification Loop > RDM Remittance Delivery Method 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 RDMBMXXXXXXX~ Max use 1 Optional RDM-01 756 Report Transmission Code Identifier (ID) 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 Min 1 Max 60 String (AN) Optional 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 Min 1 Max 256 String (AN) Optional 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 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 36/128 1000B Payee Identification Loop end Heading end Contains URL web address or e-mail address. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 37/128 Detail 2000 Header Number Loop Max >1 Optional LX 0030 Detail > Header Number Loop > LX Header Number 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 LX0~ Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 38/128 TS3 0050 Detail > Header Number Loop > TS3 Provider Summary Information 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 TS3XXXXXX20250130000000000000000000000*** 0000000000000000000000000000000000000 000000*000000000~ Max use 1 Optional TS3-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TS301 is the provider number. Usage notes This is the provider number. TS3-02 1331 Facility Type Code Min 1 Max 2 String (AN) Required 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 CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first	X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
specified in RDM01 (i.e. fax phone number and mail address). Usage notes 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 36/128 1000B Payee Identification Loop end Heading end Contains URL web address or e-mail address. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 37/128 Detail 2000 Header Number Loop Max >1 Optional LX 0030 Detail > Header Number Loop > LX Header Number 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 LX0~ Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 38/128 TS3 0050 Detail > Header Number Loop > TS3 Provider Summary Information 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 TS3XXXXXX20250130000000000000000000000**** 0000000000000000000000000000000000000 000000000000000~ Max use 1 Optional TS3-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TS301 is the provider number. Usage notes This is the provider number. TS3-02 1331 Facility Type Code Min 1 Max 2 String (AN) Required 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 CCYYMMDD format Date (DT) Required 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 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 39/128 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 Min 1 Max 15 Decimal number (R) Required 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 Min 1 Max 15 Decimal number (R) Required 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS315 is the summary of non-lab charges. Usage notes See TR3 note 3. TS3-17 782 Total HCPCS Reported Charge Amount Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 40/128 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS322 is the total patient reimbursement. Usage notes See TR3 note 3. TS3-23 380 Total PIP Claim Count Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS324 is total periodic interim payment (PIP) adjustment. Usage notes 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 41/128 See TR3 note 3. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 42/128 TS2 0070 Detail > Header Number Loop > TS2 Provider Supplemental Summary Information To provide supplemental summary control information by provider fiscal year and bill type Usage notes Required when the value of the Total DRG amount is not zero. If not required by this implementation guide, do not send. 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 TS2000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000 000000000000000000000000000000000000000000000 0000000000000000000000000000000000000000000 000000000000000~ Max use 1 Optional TS2-01 782 Total DRG Amount Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS202 is the total federal specific amount. Usage notes See TR3 note 2. TS2-03 782 Total Hospital Specific Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS203 is the total hospital specific amount. Usage notes See TR3 note 2. TS2-04 782 Total Disproportionate Share Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 43/128 Monetary amount TS204 is the total disproportionate share amount. Usage notes See TR3 note 2. TS2-05 782 Total Capital Amount Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS206 is the total indirect medical education amount. Usage notes See TR3 note 2. TS2-07 380 Total Outlier Day Count Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS208 is the total day outlier amount. Usage notes See TR3 note 2. TS2-09 782 Total Cost Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS209 is the total cost outlier amount. Usage notes 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 44/128 See TR3 note 2. TS2-10 380 Average DRG Length of Stay Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS215 is the total Medicare Secondary Payer (MSP) pass- through amount calculated for a non-Medicare payer. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 45/128 Usage notes See TR3 note 2. TS2-16 380 Average DRG weight Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS219 is the total prospective payment system (PPS) disproportionate share, hospital diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 46/128 2100 Claim Payment Information Loop Max >1 Required CLP 0100 Detail > Header Number Loop > Claim Payment Information Loop > CLP Claim Payment Information 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 CLPXXXX2100000000000000000000000000013X XXXXXXX000000000000000*00000000~ Max use 1 Required CLP-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required 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	X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
notes See TR3 note 2. TS2-11 380 Total Discharge Count Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS215 is the total Medicare Secondary Payer (MSP) pass- through amount calculated for a non-Medicare payer. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 45/128 Usage notes See TR3 note 2. TS2-16 380 Average DRG weight Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional 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 Min 1 Max 15 Decimal number (R) Optional Monetary amount TS219 is the total prospective payment system (PPS) disproportionate share, hospital diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 46/128 2100 Claim Payment Information Loop Max >1 Required CLP 0100 Detail > Header Number Loop > Claim Payment Information Loop > CLP Claim Payment Information 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 CLPXXXX2100000000000000000000000000013X XXXXXXX000000000000000*00000000~ Max use 1 Required CLP-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required 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 Identifier (ID) 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) 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 47/128 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 Min 1 Max 15 Decimal number (R) Required 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 Min 1 Max 15 Decimal number (R) Required Monetary amount CLP04 is the amount paid this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. See section 1.10.2.9 for information about interest considerations. Use this monetary amount for the amount paid for this claim. It can be positive, zero or negative, but the value in BPR02 may not be negative. CLP-05 782 Patient Responsibility Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CLP05 is the patient responsibility amount. Usage notes Amounts in CLP05 must have supporting adjustments reflected in CAS segments at the 2100 (CLP) or 2110 (SVC) loop level with a Claim Adjustment Group (CAS01) code of PR (Patient Responsibility). Use this monetary amount for the payer's statement of the patient responsibility amount for this claim, which can include such items as deductible, non-covered services, co-pay and co-insurance. This is not used for reversals. See section 1.10.2.8, Reversals and Corrections, for additional information. CLP-06 1032 Claim Filing Indicator Code Identifier (ID) Required 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 48/128 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 Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CLP07 is the payer's internal control number. Usage notes 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 49/128 Use this number for the payer's internal control number. This number must apply to the entire claim. CLP-08 1331 Facility Type Code Min 1 Max 2 String (AN) Optional Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. Usage notes Since professional or dental claims can have different place of service codes for services within a single claim, default to the place of service of the first service line when the service lines are not all for the same place of service. This number was received in CLM05-1 of the 837 claim. CLP-09 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Optional Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type Usage notes This number was received in CLM05-3 of the 837 Claim. CLP-11 1354 Diagnosis Related Group (DRG) Code Min 1 Max 4 Identifier (ID) Optional Code indicating a patient's diagnosis group based on a patient's illness, diseases, and medical problems CLP-12 380 Diagnosis Related Group (DRG) Weight Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CLP12 is the diagnosis-related group (DRG) weight. Usage notes This is the adjudicated DRG Weight. CLP-13 954 Discharge Fraction Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%) CLP13 is the discharge fraction. Usage notes This is the adjudicated discharge fraction. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 50/128 CAS 0200 Detail > Header Number Loop > Claim Payment Information Loop > CAS Claim Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Payers must use this CAS segment to report claim level adjustments that cause the amount paid to differ from the amount originally charged. See 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. See the SVC TR3 Note #1 for details about per diem adjustments. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment must be the first non-zero adjustment and is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Required when dollar amounts and/or	X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
notes 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 49/128 Use this number for the payer's internal control number. This number must apply to the entire claim. CLP-08 1331 Facility Type Code Min 1 Max 2 String (AN) Optional Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. Usage notes Since professional or dental claims can have different place of service codes for services within a single claim, default to the place of service of the first service line when the service lines are not all for the same place of service. This number was received in CLM05-1 of the 837 claim. CLP-09 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Optional Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type Usage notes This number was received in CLM05-3 of the 837 Claim. CLP-11 1354 Diagnosis Related Group (DRG) Code Min 1 Max 4 Identifier (ID) Optional Code indicating a patient's diagnosis group based on a patient's illness, diseases, and medical problems CLP-12 380 Diagnosis Related Group (DRG) Weight Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CLP12 is the diagnosis-related group (DRG) weight. Usage notes This is the adjudicated DRG Weight. CLP-13 954 Discharge Fraction Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%) CLP13 is the discharge fraction. Usage notes This is the adjudicated discharge fraction. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 50/128 CAS 0200 Detail > Header Number Loop > Claim Payment Information Loop > CAS Claim Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Payers must use this CAS segment to report claim level adjustments that cause the amount paid to differ from the amount originally charged. See 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. See the SVC TR3 Note #1 for details about per diem adjustments. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment must be the first non-zero adjustment and is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Required when dollar amounts and/or quantities are being adjusted at the claim level. If not required by this implementation guide, do not send. Example CASPRXX0000000000000000XXX0000000000000000 00000000XXXX00000000000000000000000XXX000000 000000XX000000000000000000000000000XXX00000 000000000000000~ If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS- 07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 51/128 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer/payee contractual agreement or a regulatory requirement resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. 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 Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the claim level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes See section 1.10.2.4.1 for additional information. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 52/128 A positive value decreases the covered days, and a negative number increases the covered days. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 53/128 Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 54/128 Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 55/128 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Patient Name To supply the full name of an individual or organizational entity Usage notes Provide the patient's identification number in NM109. This segment must provide the information from the original claim. For example, when the claim is submitted as an ASC X12 837 transaction, this is the 2010CA loop NM1 Patient Name Segment unless not present on the original claim, then it is the 2010BA loop NM1 Subscriber name segment. The Corrected Patient/Insured Name NM1 segment identifies the adjudicated Insured Name and ID information if different than what was submitted on the claim. Example NM1QC1XXXXXXXXXXXXX*XXXXXXMR*XXXXXX~ Variants (all may be used) NM1 Insured Name NM1 Corrected Patient/Insured Name NM1 Service Provider Name NM1 Crossover Carrier Name NM1 Corrected Priority Payer Name NM1 Other Subscriber Name If either Identification Code Qualifier (NM1-08) or Patient Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual QC Patient NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Patient Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Patient First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Patient Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 56/128 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Patient Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes An example of this is when a Junior and Senior are covered under the same subscriber. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) 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 Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 57/128 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Insured Name 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	X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
CAS19 is the units of service being adjusted. Usage notes See CAS04. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 55/128 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Patient Name To supply the full name of an individual or organizational entity Usage notes Provide the patient's identification number in NM109. This segment must provide the information from the original claim. For example, when the claim is submitted as an ASC X12 837 transaction, this is the 2010CA loop NM1 Patient Name Segment unless not present on the original claim, then it is the 2010BA loop NM1 Subscriber name segment. The Corrected Patient/Insured Name NM1 segment identifies the adjudicated Insured Name and ID information if different than what was submitted on the claim. Example NM1QC1XXXXXXXXXXXXXXXXXXXMRXXXXXX~ Variants (all may be used) NM1 Insured Name NM1 Corrected Patient/Insured Name NM1 Service Provider Name NM1 Crossover Carrier Name NM1 Corrected Priority Payer Name NM1 Other Subscriber Name If either Identification Code Qualifier (NM1-08) or Patient Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual QC Patient NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Patient Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Patient First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Patient Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 56/128 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Patient Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes An example of this is when a Junior and Senior are covered under the same subscriber. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) 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 Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 57/128 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Insured Name 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 NM1IL2XXXXXXXXXXXXXXX*XXXXXXIIXXXXX~ Variants (all may be used) NM1 Patient Name NM1 Corrected Patient/Insured Name NM1 Service Provider Name NM1 Crossover Carrier Name NM1 Corrected Priority Payer Name NM1 Other Subscriber Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Subscriber Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 58/128 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 Min 1 Max 10 String (AN) Optional 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 Identifier (ID) 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 Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 59/128 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Corrected Patient/Insured Name To supply the full name of an individual or organizational entity Usage notes Since the patient is always the insured for Medicare and Medicaid, this segment always provides corrected patient information for Medicare and Medicaid. For other carriers, this will always be the corrected insured information. Required when needed to provide corrected information about the patient or insured. If not required by this implementation guide, do not send. Example NM1742XXXXXXXX*XCXXX~ Variants (all may be used) NM1 Patient Name NM1 Insured Name NM1 Service Provider Name NM1 Crossover Carrier Name NM1 Corrected Priority Payer Name NM1 Other Subscriber Name If either Identification Code Qualifier (NM1-08) or Corrected Insured Identification Indicator (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 74 Corrected Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Corrected Patient or Insured Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Corrected Patient or Insured First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Corrected Patient or Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 60/128 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Corrected Patient or Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) C Insured's Changed Unique Identification Number NM1-09 67 Corrected Insured Identification Indicator Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 61/128 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Service Provider Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the rendering provider. An identification number is provided in NM109. This information is provided to facilitate identification of the claim within a payee's system. Other providers (e.g., Referring provider, supervising provider) related to the claim but not directly related to the payment are not supported and are not necessary for claim identification. Required when the rendering provider is different from the payee. If not required by this implementation guide, do not send. Example NM1821XXXXXXXXXXXX*XXXXXXBSXXXXXX~ Variants (all may be used) NM1 Patient Name NM1 Insured Name NM1 Corrected Patient/Insured Name NM1 Crossover Carrier Name NM1 Corrected Priority Payer Name NM1 Other Subscriber Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 62/128 Individual middle name or initial Usage notes If this data element is used and contains only one character, it represents the middle initial. NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) BD Blue Cross Provider Number BS Blue Shield Provider Number FI Federal Taxpayer's Identification Number This is the preferred ID until the National Provider ID is mandated and applicable. For individual providers as payees, use this qualifier to represent the Social Security Number. MC Medicaid Provider Number PC Provider Commercial Number SL State License Number UP Unique Physician Identification Number (UPIN) XX Centers for Medicare and Medicaid Services National Provider Identifier Required value if the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate. Otherwise, one of the other listed codes may be used. NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 63/128 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Crossover Carrier Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the crossover carrier. Provide any reference numbers in NM109. The crossover carrier is defined as any payer to which the claim is transferred for further payment after being finalized by the current payer. Required when the claim is transferred to another carrier or coverage (CLP02 equals 19, 20, 21 or 23). If not required by this implementation guide, do not send. Example NM1TT2XXXXXX****NIXXXX~ Variants (all may be used) NM1 Patient Name NM1 Insured Name NM1 Corrected Patient/Insured Name NM1 Service Provider Name NM1 Corrected Priority Payer Name NM1 Other Subscriber Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual TT Transfer To NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Crossover Carrier Name Min 1 Max 60 String (AN) Required Individual last name or organizational name Usage notes Name of the crossover carrier associated with this claim. NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) 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 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 64/128 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	X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
62/128 Individual middle name or initial Usage notes If this data element is used and contains only one character, it represents the middle initial. NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) BD Blue Cross Provider Number BS Blue Shield Provider Number FI Federal Taxpayer's Identification Number This is the preferred ID until the National Provider ID is mandated and applicable. For individual providers as payees, use this qualifier to represent the Social Security Number. MC Medicaid Provider Number PC Provider Commercial Number SL State License Number UP Unique Physician Identification Number (UPIN) XX Centers for Medicare and Medicaid Services National Provider Identifier Required value if the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate. Otherwise, one of the other listed codes may be used. NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 63/128 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Crossover Carrier Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the crossover carrier. Provide any reference numbers in NM109. The crossover carrier is defined as any payer to which the claim is transferred for further payment after being finalized by the current payer. Required when the claim is transferred to another carrier or coverage (CLP02 equals 19, 20, 21 or 23). If not required by this implementation guide, do not send. Example NM1TT2XXXXXX***NIXXXX~ Variants (all may be used) NM1 Patient Name NM1 Insured Name NM1 Corrected Patient/Insured Name NM1 Service Provider Name NM1 Corrected Priority Payer Name NM1 Other Subscriber Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual TT Transfer To NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Crossover Carrier Name Min 1 Max 60 String (AN) Required Individual last name or organizational name Usage notes Name of the crossover carrier associated with this claim. NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) 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 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 64/128 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 Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 65/128 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Corrected Priority Payer Name To supply the full name of an individual or organizational entity Usage notes Provide any reference numbers in NM109. Use of this segment identifies the priority payer. Do not use this segment when the Crossover Carrier NM1 segment is used. Required when current payer believes that another payer has priority for making a payment and the claim is not being automatically transferred to that payer. If not required by this implementation guide, do not send. Example NM1PR2XXXX***NIXXXXXXX~ Variants (all may be used) NM1 Patient Name NM1 Insured Name NM1 Corrected Patient/Insured Name NM1 Service Provider Name NM1 Crossover Carrier Name NM1 Other Subscriber Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Corrected Priority Payer Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) AD Blue Cross Blue Shield Association Plan Code FI Federal Taxpayer's Identification Number NI National Association of Insurance Commissioners (NAIC) Identification This is the preferred ID unless XV is used. PI Payor Identification PP Pharmacy Processor Number XV Centers for Medicare and Medicaid Services PlanID 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 66/128 Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used. NM1-09 67 Corrected Priority Payer Identification Number Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 67/128 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes This is the name and ID number of the other subscriber when a corrected priority payer has been identified. When used, either the name or ID must be supplied. Required when a corrected priority payer has been identified in another NM1 segment AND the name or ID of the other subscriber is known. If not required by this implementation guide, do not send. Example NM1GB1XXXXXXXXXXXXXXXXXXXXFIXX~ Variants (all may be used) NM1 Patient Name NM1 Insured Name NM1 Corrected Patient/Insured Name NM1 Service Provider Name NM1 Crossover Carrier Name NM1 Corrected Priority Payer Name If either Identification Code Qualifier (NM1-08) or Other Subscriber Identifier (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual GB Other Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Subscriber Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name Usage notes At least one of NM103 or NM109 must be present. NM1-04 1036 Other Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 68/128 Individual middle name or initial Usage notes When only one character is present this is assumed to be the middle initial. NM1-07 1039 Other Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Not Used when NM102=1. II Standard Unique Health Identifier for each Individual in the United States Use this code if mandated in a final Federal Rule. MI Member Identification Number Use this code when supplying the number used for identification of the subscriber in NM109. NM1-09 67 Other Subscriber Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes At least one of NM103 or NM109 must be present. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 69/128 MIA 0330 Detail > Header Number Loop > Claim Payment Information Loop > MIA Inpatient Adjudication Information To provide claim-level data related to the adjudication of Medicare inpatient claims Usage notes When used outside of the Medicare and Medicaid community only MIA01, 05, 20, 21, 22 and 23 may be used. Either MIA or MOA may appear, but not both. This segment must not be used for covered days or lifetime reserve days. For covered or lifetime reserve days, use the Supplemental Claim Information Quantities Segment in the Claim Payment Loop. All situational quantities and/or monetary amounts in this segment are required when the value of the item is different than zero. Required for all inpatient claims when there is a need to report Remittance Advice Remark Codes at the claim level or, the claim is paid by Medicare or Medicaid under the Prospective Payment System (PPS). If not required by this implementation guide, do not send. Example MIA000000000000000000000000000000000000000000 000XXX000000000000000000000000000000000000000 0000000000000000000000000000000000000000000 0000000000000000000000000000000000000000000 0000000XXXXXXXXXXXXXXXXXXX*00000000~ Max use 1 Optional MIA-01 380 Covered Days or Visits Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity MIA01 is the covered days. Usage notes Implementers utilizing the MIA segment always transmit the number zero. See the QTY segment at the claim level for covered days or visits count. MIA-02 782 PPS Operating Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA02 is the Prospective Payment System (PPS) Operating Outlier amount. Usage notes See TR3 note 4. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MIA-03 380 Lifetime Psychiatric Days Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA03 is the lifetime psychiatric days. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 70/128 MIA-04 782 Claim DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA04 is the Diagnosis Related Group (DRG) amount. MIA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA05 is the Claim Payment Remark Code. See Code Source 411. MIA-06 782 Claim Disproportionate Share Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA06 is the disproportionate share amount. MIA-07 782 Claim MSP Pass-through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA07 is the Medicare Secondary Payer (MSP) pass-through amount. MIA-08 782 Claim PPS Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA08 is the total Prospective Payment System (PPS) capital amount. MIA-09 782 PPS-Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 71/128 MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782	X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
(PPS) Operating Outlier amount. Usage notes See TR3 note 4. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MIA-03 380 Lifetime Psychiatric Days Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA03 is the lifetime psychiatric days. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 70/128 MIA-04 782 Claim DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA04 is the Diagnosis Related Group (DRG) amount. MIA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA05 is the Claim Payment Remark Code. See Code Source 411. MIA-06 782 Claim Disproportionate Share Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA06 is the disproportionate share amount. MIA-07 782 Claim MSP Pass-through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA07 is the Medicare Secondary Payer (MSP) pass-through amount. MIA-08 782 Claim PPS Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA08 is the total Prospective Payment System (PPS) capital amount. MIA-09 782 PPS-Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 71/128 MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 72/128 Monetary amount MIA19 is the professional component amount billed but not payable. MIA-20 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA20 is the Claim Payment Remark Code. See Code Source 411. MIA-21 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA21 is the Claim Payment Remark Code. See Code Source 411. MIA-22 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 73/128 MOA 0350 Detail > Header Number Loop > Claim Payment Information Loop > MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required when the outpatient institutional claim reimbursement rate is not zero for a Medicare or Medicaid claim. If not required by this implementation guide, do not send. 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 MOA000000000000000XXXXXXXXXXXXXXXXXX00000 0000000~ Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%) MOA01 is the reimbursement rate. MOA-02 782 Claim HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 74/128 MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 Claim ESRD Payment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 75/128 REF 0400 Detail > Header Number Loop > Claim Payment Information Loop > REF Other Claim Related Identification To specify identifying information Usage notes Required when additional reference numbers specific to the claim in the CLP segment are provided to identify information used in the process of adjudicating this claim. If not required by this implementation guide, do not send. Example REFCEXXXXXX~ Variants (all may be used) REF Rendering Provider Identification Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) 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 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 76/128 REF-02 127 Other Claim Related Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 77/128 REF 0400 Detail > Header Number Loop > Claim Payment Information Loop > REF Rendering Provider Identification 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 REF1J*XX~ Variants (all may be used) REF Other Claim Related Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) 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 Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 78/128 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Statement From or To Date To specify pertinent dates and times Usage notes Dates at the claim level apply to the entire claim, including all service lines. Dates at the service line level apply only to the service line where they appear. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. For retail pharmacy claims, the Claim Statement Period Start Date is equivalent to the prescription filled date. Required when the "Statement From or To Dates" are not supplied at the service (2110 loop) level. If not required by this implementation guide, may be provided at senders discretion, but cannot be required by the receiver. For predeterminations, where there is no service date, the	X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 76/128 REF-02 127 Other Claim Related Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 77/128 REF 0400 Detail > Header Number Loop > Claim Payment Information Loop > REF Rendering Provider Identification 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 REF1JXX~ Variants (all may be used) REF Other Claim Related Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) 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 Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 78/128 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Statement From or To Date To specify pertinent dates and times Usage notes Dates at the claim level apply to the entire claim, including all service lines. Dates at the service line level apply only to the service line where they appear. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. For retail pharmacy claims, the Claim Statement Period Start Date is equivalent to the prescription filled date. Required when the "Statement From or To Dates" are not supplied at the service (2110 loop) level. If not required by this implementation guide, may be provided at senders discretion, but cannot be required by the receiver. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM23320250130~ Variants (all may be used) DTM Coverage Expiration Date DTM Claim Received Date Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 232 Claim Statement Period Start If the claim statement period start date is conveyed without a subsequent claim statement period end date, the end date is assumed to be the same as the start date. This date or code 233 is required when service level dates are not provided in the remittance advice. 233 Claim Statement Period End If a claim statement period end date is conveyed without a claim statement period start date, then the start date is assumed to be different from the end date but not conveyed at the payer's discretion. See the note on code 232. DTM-02 373 Claim Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 79/128 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Coverage Expiration Date To specify pertinent dates and times Usage notes Required when payment is denied because of the expiration of coverage. If not required by this implementation guide, do not send. Example DTM03620250130~ Variants (all may be used) DTM Statement From or To Date DTM Claim Received Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 036 Expiration DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the expiration date of the patient's coverage. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 80/128 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Claim Received Date To specify pertinent dates and times Usage notes Required whenever state or federal regulations or the provider contract mandate interest payment or prompt payment discounts based upon the receipt date of the claim by the payer. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example DTM05020250130~ Variants (all may be used) DTM Statement From or To Date DTM Coverage Expiration Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the date that the claim was received by the payer. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 81/128 PER 0600 Detail > Header Number Loop > Claim Payment Information Loop > PER Claim Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when there is a claim specific communications contact. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800)555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number. Example PERCXXFXXXXXXFXXXXXXXEXXXXXX~ If either Communication Number Qualifier (PER-05) or Claim Contact Communications Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number Extension (PER-08) is present, then the other is required Max use 2 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Claim Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 82/128 EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Communication Number Extension Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 83/128 AMT 0620 Detail > Header Number Loop > Claim Payment Information Loop > AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send/receive one AMT for each applicable non-zero value. Do not report any zero values. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTZO0000000~ Max use 13 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount AU Coverage Amount Use this monetary amount to report the total covered charges. This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan. This excludes charges considered not covered (i.e. per day television or telephone charges) but includes reductions to payments of covered services (i.e. reductions for amounts over fee schedule and patient deductibles). 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 Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 84/128 Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 85/128 QTY 0640 Detail > Header Number Loop > Claim Payment Information Loop > QTY Claim Supplemental Information Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send one QTY for each non-zero value. Do not report any zero values. Required when the value of a specific quantity identified by the QTY01 qualifier is non- zero. If not required by this implementation guide, do not send. Example QTYCA00000~ Max use 14 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity CA Covered - Actual CD Co-insured - Actual LA Life-time Reserve - Actual 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 Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 86/128 2110 Service Payment Information Loop Max 999 Optional SVC 0700 Detail	X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
Code Identifier (ID) Required Code to qualify amount AU Coverage Amount Use this monetary amount to report the total covered charges. This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan. This excludes charges considered not covered (i.e. per day television or telephone charges) but includes reductions to payments of covered services (i.e. reductions for amounts over fee schedule and patient deductibles). 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 Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 84/128 Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 85/128 QTY 0640 Detail > Header Number Loop > Claim Payment Information Loop > QTY Claim Supplemental Information Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send one QTY for each non-zero value. Do not report any zero values. Required when the value of a specific quantity identified by the QTY01 qualifier is non- zero. If not required by this implementation guide, do not send. Example QTYCA00000~ Max use 14 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity CA Covered - Actual CD Co-insured - Actual LA Life-time Reserve - Actual 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 Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 86/128 2110 Service Payment Information Loop Max 999 Optional SVC 0700 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > SVC Service Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO7825~). See section 1.10.2.4.1 for additional information. See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information. Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send. Example SVCAD>XXXX>XX>XX>XX>XX000000000000000000000XX XXX0000000000ER>XXXXX>XX>XX>XX>XX>X00000000~ Max use 1 Required SVC-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132). Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7. 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 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 87/128 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 Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 88/128 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. SVC-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC02 is the submitted service charge. Usage notes Use this monetary amount for the submitted service charge amount. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. SVC-03 782 Line Item Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC03 is the amount paid this service. Usage notes Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. See 1.10.2.1, Balancing, for additional information. SVC-04 234 National Uniform Billing Committee Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service SVC04 is the National Uniform Billing Committee Revenue Code. Usage notes If the original claim and adjudication only referenced an NUBC revenue code, that is supplied in SVC01 and this element is not used. SVC-05 380 Units of Service Paid Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC05 is the paid units of service. Usage notes If not present, the value is assumed to be one. SVC-06 C003 Composite Medical Procedure Identifier Max use 1 Optional 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 89/128 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 Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7. 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 Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 90/128 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances	X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
380 Units of Service Paid Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC05 is the paid units of service. Usage notes If not present, the value is assumed to be one. SVC-06 C003 Composite Medical Procedure Identifier Max use 1 Optional 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 89/128 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 Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7. 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 Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 90/128 This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVC-07 380 Original Units of Service Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC07 is the original submitted units of service. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 91/128 DTM 0800 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > DTM Service Date To specify pertinent dates and times Usage notes Dates at the service line level apply only to the service line where they appear. If used for inpatient claims and no service date was provided on the claim then report the through date from the claim level. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. Required when claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. For retail pharmacy claims, the service date is equivalent to the prescription filled date. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM15120250130~ Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 150 Service Period Start This qualifier is required for reporting the beginning of multi-day services. If not required by this implementation guide, do not send. 151 Service Period End This qualifier is required for reporting the end of multi-day services. If not required by this implementation guide, do not send. 472 Service This qualifier is required to indicate a single day service. If not required by this implementation guide, do not send. DTM-02 373 Service Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 92/128 CAS 0900 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > CAS Service Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes An example of this level of CAS is the reduction for the part of the service charge that exceeds the usual and customary charge for the service. See sections 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02). If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CASPRXXXXX000000000000XXXXX0000000X000 000XXX00000000000000000000000XXXX0000000000 000000XX0000000000000*000000000000000~ If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS- 07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 93/128 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer/payee agreement or a regulatory requirement has resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. 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 Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03 and CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 94/128 A positive number decreases paid units, and a negative value increases paid units. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 95/128 CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity	X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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 Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03 and CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 94/128 A positive number decreases paid units, and a negative value increases paid units. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 95/128 CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 96/128 Usage notes See CAS02. CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. Usage notes See CAS03. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 97/128 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Service Identification To specify identifying information Usage notes Required when related service specific reference identifiers were used in the process of adjudicating this service. If not required by this implementation guide, do not send. Example REF1SX~ Variants (all may be used) REF Line Item Control Number REF Rendering Provider Information REF HealthCare Policy Identification Max use 8 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1S Ambulatory Patient Group (APG) Number APC Ambulatory Payment Classification 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 Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 98/128 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Line Item Control Number To specify identifying information Usage notes This is the Line Item Control Number submitted in the 837, which is utilized by the provider for tracking purposes. See section 1.10.2.11 and 1.10.2.14.1 for additional information on usage with split claims or services. Note - the value in REF02 can include alpha characters. Required when a Line Item Control Number was received on the original claim or when claim or service line splitting has occurred. If not required by this implementation guide, do not send. Example REF6RXXXXX~ Variants (all may be used) REF Service Identification REF Rendering Provider Information REF HealthCare Policy Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 99/128 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Rendering Provider Information To specify identifying information Usage notes Required when the rendering provider for this service is different than the rendering provider applicable at the claim level. If not required by this implementation guide, do not send. Example REFHPIXXXXXX~ Variants (all may be used) REF Service Identification REF Line Item Control Number REF HealthCare Policy Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) 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 Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 100/128 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF HealthCare Policy Identification To specify identifying information Usage notes Required when; The payment is adjusted in accordance with the Payer's published Healthcare Policy Code list and A Claim Adjustment Reason Code identified by the notation, "refer to 835 Healthcare Policy identification segment", in the Claim Adjustment Reason Code List is present in a related CAS segment and The payer has a published enumerated healthcare policy code list available to healthcare providers via an un-secure public website and The payer wishes to supply this policy detail to reduce provider inquiries. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Healthcare Policy - A clinical/statutory rule use to determine claim adjudication that cannot be explained by the sole use of a claim adjustment reason code in the CAS segment and Remittance Advise Remark code when appropriate. The term Healthcare Policy is intended to include Medical Review Policy, Dental Policy Review, Property and Casualty Policies, Workers Comp Policies and Pharmacy Policies for example Medicare LMRP's.( Local Medicare Review policies) and NCD (National Coverage Determinations). This policy segment must not be used to provide a proprietary explanation code or reason for adjustment. Supply the Healthcare policy identifier in REF02 as provided by the payer's published Healthcare policy code list. This policy code will be used to explain the policy used to process the claim which resulted in the adjusted payment. 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 REF0KXXXXXX~ Variants (all may be used) REF Service Identification REF Line Item Control Number REF Rendering Provider Information Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0K Policy Form Identifying Number REF-02 127 Healthcare Policy Identification Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 101/128 AMT 1100 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > AMT Service Supplemental Amount To indicate the total monetary amount Usage notes This segment is used to convey information only. It is not part of the financial balancing of the 835. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTZO0000~ Max use 9 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount B6 Allowed - Actual Allowed amount is the amount the payer deems payable prior to considering patient responsibility. KH Deduction Amount Late Filing Reduction 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 Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 102/128 QTY 1200 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > QTY Service Supplemental Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Required when new Federal Medicare or Medicaid mandates require Quantity counts and value of specific quantities	X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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 REF0KXXXXXX~ Variants (all may be used) REF Service Identification REF Line Item Control Number REF Rendering Provider Information Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0K Policy Form Identifying Number REF-02 127 Healthcare Policy Identification Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 101/128 AMT 1100 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > AMT Service Supplemental Amount To indicate the total monetary amount Usage notes This segment is used to convey information only. It is not part of the financial balancing of the 835. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTZO0000~ Max use 9 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount B6 Allowed - Actual Allowed amount is the amount the payer deems payable prior to considering patient responsibility. KH Deduction Amount Late Filing Reduction 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 Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 102/128 QTY 1200 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > QTY Service Supplemental Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Required when new Federal Medicare or Medicaid mandates require Quantity counts and value of specific quantities identified in the QTY01 qualifier are non-zero. If not required by this implementation guide, do not send. Example QTYZL00000000~ Max use 6 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Service Supplemental Quantity Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 103/128 2110 Service Payment Information Loop end 2100 Claim Payment Information Loop end 2000 Header Number Loop end Detail end LQ 1300 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > LQ Health Care Remark Codes To identify standard industry codes Usage notes Use this segment to provide informational remarks only. This segment has no impact on the actual payment. Changes in claim payment amounts are provided in the CAS segments. Required when remark codes or NCPDP Reject/Payment codes are necessary for the provider to fully understand the adjudication message for a given service line. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example LQHEX~ If Code List Qualifier Code (LQ-01) is present, then Remark Code (LQ-02) is required Max use 99 Optional LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list HE Claim Payment Remark Codes RX National Council for Prescription Drug Programs Reject/Payment Codes LQ-02 1271 Remark Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 104/128 Summary PLB 0100 Summary > PLB Provider Adjustment To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service Usage notes These adjustments can either decrease the payment (a positive number) or increase the payment (a negative number). Zero dollar adjustments are not allowed. Some examples of PLB adjustments are a Periodic Interim Payment (loans and loan repayment) or a capitation payment. Multiple adjustments can be placed in one PLB segment, grouped by the provider identified in PLB01 and the period identified in PLB02. Although the PLB reference numbers are not standardized, refer to 1.10.2.9 (Interest and Prompt Payment Discounts), 1.10.2.10 (Capitation and Related Payments or Adjustments), 1.10.2.12 (Balance Forward Processing), 1.10.2.16 (Post Payment Recovery) and 1.10.2.17 (Claim Overpayment Recovery) for code suggestions and usage guidelines. The codes and notations under PLB03 and its components apply equally to PLB05, 07, 09, 11 and 13. Required when reporting adjustments to the actual payment that are NOT specific to a particular claim or service. If not required by this implementation guide, do not send. Example PLBXXXXXX20250130LE>XXXX000000000000000XX>XX X000000000XX>XXXXX000000000000000XX>XXXX000 0XX>X00000000XX>XXXX00000000~ If either Adjustment Identifier (PLB-05) or Provider Adjustment Amount (PLB-06) is present, then the other is required If either Adjustment Identifier (PLB-07) or Provider Adjustment Amount (PLB-08) is present, then the other is required If either Adjustment Identifier (PLB-09) or Provider Adjustment Amount (PLB-10) is present, then the other is required If either Adjustment Identifier (PLB-11) or Provider Adjustment Amount (PLB-12) is present, then the other is required If either Adjustment Identifier (PLB-13) or Provider Adjustment Amount (PLB-14) is present, then the other is required Max use >1 Optional PLB-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB01 is the provider number assigned by the payer. Usage notes When the National Provider Identifier (NPI) is mandated and the provider is a covered health care provider under that mandate, this must be the NPI assigned to the provider. Until the NPI is mandated, this is the provider identifier as assigned by the payer. PLB-02 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 105/128 year PLB02 is the last day of the provider's fiscal year. Usage notes This is the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known by the payer, use December 31st of the current year. PLB-03 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB03 is the adjustment information as defined by the payer. Max use 1 Required C042-01 426 Adjustment Reason Code Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment 50 Late Charge This is the Late Claim Filing Penalty or Medicare Late Cost Report Penalty. 51 Interest Penalty Charge This is the interest assessment for late filing. 72 Authorized Return This is the provider refund adjustment. This adjustment acknowledges a refund received from a provider for previous overpayment. PLB03-2 must always contain an identifying reference number when the value is used. PLB04 must contain a negative value. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. 90 Early Payment Allowance 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. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 106/128 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	X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 106/128 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 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 107/128 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 Min 1 Max 50 String (AN) Optional 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 Min 1 Max 15 Decimal number (R) Required 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 Max use 1 Optional 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 108/128 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 Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-06 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 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. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-08 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB08 is the adjustment amount. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 109/128 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. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-10 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 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. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 110/128 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-12 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 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. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-14 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB14 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 111/128 Summary end SE 0200 Summary > SE Transaction Set Trailer To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments) Example SE0000001~ Max use 1 Required SE-01 96 Transaction Segment Count Min 1 Max 10 Numeric (N0) Required Total number of segments included in a transaction set including ST and SE segments SE-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required 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. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 112/128 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE00000000000000~ Max use 1 Required GE-01 97 Number of Transaction Sets Included Min 1 Max 6 Numeric (N0) Required 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 Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 113/128 IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA00000000000~ Max use 1 Required IEA-01 I16 Number of Included Functional Groups Min 1 Max 5 Numeric (N0) Required A count of the number of functional groups included in an interchange IEA-02 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned	X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
Min 1 Max 15 Decimal number (R) Optional 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. Max use 1 Optional C042-01 426 Adjustment Reason Code Min 2 Max 2 Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment C042-02 127 Provider Adjustment Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-14 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB14 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 111/128 Summary end SE 0200 Summary > SE Transaction Set Trailer To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments) Example SE0000001~ Max use 1 Required SE-01 96 Transaction Segment Count Min 1 Max 10 Numeric (N0) Required Total number of segments included in a transaction set including ST and SE segments SE-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required 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. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 112/128 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE00000000000000~ Max use 1 Required GE-01 97 Number of Transaction Sets Included Min 1 Max 6 Numeric (N0) Required 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 Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 113/128 IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA00000000000~ Max use 1 Required IEA-01 I16 Number of Included Functional Groups Min 1 Max 5 Numeric (N0) Required A count of the number of functional groups included in an interchange IEA-02 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 114/128 EDI Samples Example 1: Dollars and Data Sent Separately ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST835112233~ BPRI1100CACHCCP01888999777DA246810121935665544*01111333555DA14444420190316~ TRN1717006665551935665544~ DTM40520190314~ N1PRRUSHMORE LIFE~ N310 SOUTH AVENUET~ N4RAPID CITYSD55111~ PERBLJOHN WAYNETE8005551212EX123~ N1PEACME MEDICAL CENTERXX5544667733~ REFTJ777667755~ LX1~ CLP555455544418005003001294060555410000111~ NM1QC1BUDDWILLIAM***MI33344555510~ AMTAU800~ SVCHC>99211800500~ DTM47220190301~ CASPR1300~ AMTB6800~ CLP876543211211200600600129407779923000111~ NM1QC1SETTLESUSAN**MI44455666610~ AMTAU1200~ SVCHC>935551200600~ DTM47220190310~ CASPR1600~ AMTB61200~ SE26112233~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 115/128 Example 2: Multiple Claims Single Check ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83535681~ BPRI810.8CCHK***********20190331~ TRN1123451512345678~ REFEVXYZ CLEARINGHOUSE~ N1PRDENTAL OF ABC~ N3225 MAIN STREET~ N4CENTERVILLEPA17111~ PERBLJANE DOETE9005555555~ N1PEBAN DDS LLCXX9999947036~ REFTJ212121212~ LX1~ CLP7722337122613212119932404007801111~ NM1QC1DOESANDY***MISJD11112~ NM1821BANERIN***XX1811901945~ AMTAU132~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D02202514~ DTM47220190324~ CASCO4511~ AMTB614~ SVCAD>D02302210~ DTM47220190324~ CASCO4512~ AMTB610~ SVCAD>D02746034~ DTM47220190324~ CASCO4526~ AMTB634~ SVCAD>D11107349~ DTM47220190324~ CASCO4524~ AMTB649~ CLP7722337111974*12119932404007801111~ NM1QC1DOESALLY***MISJD11111~ NM1IL1DOEJOHN***MISJD11111~ NM1821BANERIN***XX1811901945~ AMTAU74~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D11107349~ DTM47220190324~ CASCO4524~ AMTB649~ CLP772233712261082412119932404007801111~ NM1QC1SMITHSALLY**MISJD11113~ NM1821BANERIN***XX1811901945~ AMTAU132~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 116/128 AMTB625~ SVCAD>D0220250~ DTM47220190324~ CASPR314~ CASCO4511~ AMTB614~ SVCAD>D0230220~ DTM47220190324~ CASPR310~ CASCO4512~ AMTB610~ SVCAD>D02746034~ DTM47220190324~ CASCO4526~ AMTB634~ SVCAD>D11107349~ DTM47220190324~ CASCO4524~ AMTB649~ CLP7722337111451490212119932404007801111~ NM1QC1SMITHSAM**MISJD11116~ NM1821BANERIN***XX1811901945~ AMTAU14~ SVCAD>D02202514~ DTM47220190324~ CASCO4511~ AMTB614~ SVCAD>D27909400~ DTM47220190324~ CASPR3756~ CASCO45184~ SVCAD>D29501800~ DTM47220190324~ CASPR3146~ CASCO4534~ CLP7722337134816.844.212119932404007801111~ NM1QC1JONESSAM**MISJD11122~ NM1821BANERIN***XX1811901945~ AMTAU28~ SVCAD>D43421250~ DTM47220190313~ CASCO45125~ SVCAD>D4381430~ DTM47220190313~ CASPR333~ CASCO4510~ SVCAD>D295018016.8~ DTM47220190313~ CASPR311.2~ CASCO45152~ AMTB628~ CLP77223371226132*12119932404007801111~ NM1QC1JONESSALLY***MISJD11133~ NM1821BANERIN***XX1811901945~ AMTAU132~ SVCAD>D01204625~ DTM47220190321~ CASCO4521~ AMTB625~ SVCAD>D02202514~ 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 117/128 DTM47220190321~ CASCO4511~ AMTB614~ SVCAD>D02302210~ DTM47220190321~ CASCO4512~ AMTB610~ SVCAD>D02746034~ DTM47220190321~ CASCO4526~ AMTB634~ SVCAD>D11107349~ DTM47220190321~ CASCO4524~ AMTB649~ CLP77223371179108*12119932404007801111~ NM1QC1DOESAM***MISJD99999~ NM1821BANERIN***XX1811901945~ AMTAU108~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D02746034~ DTM47220190324~ CASCO4526~ AMTB634~ SVCAD>D11107349~ DTM47220190324~ CASCO4524~ AMTB649~ CLP7722337112982*12119932404007801111~ NM1QC1DOESUE***MISJD88888~ NM1821BANERIN***XX1811901945~ AMTAU82~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D11205437~ DTM47220190324~ CASCO4517~ AMTB637~ SVCAD>D12082920~ DTM47220190324~ CASCO459~ AMTB620~ CLP77223371221144*12119932404007801111~ NM1QC1DOEDONNA***MISJD77777~ NM1821BANERIN***XX1811901945~ AMTAU144~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D03309262~ DTM47220190324~ CASCO4530~ AMTB662~ SVCAD>D11205437~ 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 118/128 DTM47220190324~ CASCO4517~ AMTB637~ SVCAD>D12082920~ DTM47220190324~ CASCO459~ AMTB620~ SE18335681~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 119/128 Example 3: Claim Specific Negotiated Discount ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83535681~ BPRI132CCHK***********20190331~ TRN1123451512345678~ REFEVCLEARINGHOUSE~ N1PRDELTA DENTAL OF ABC~ N3225 MAIN STREET~ N4CENTERVILLEPA17111~ PERBLJANE DOETE9005555555~ N1PEBAN DDS LLCFI999994703~ LX1~ CLP7722337122613212119932404007801~ NM1QC1DOESALLY***MISJD11111~ NM1821BANERIN***XX1811901945~ AMTAU132~ SVCAD>D01204625~ DTM47220190324~ CASCO13121~ AMTB625~ SVCAD>D02202514~ DTM47220190324~ CASCO13111~ AMTB614~ SVCAD>D02302210~ DTM47220190324~ CASCO13112~ AMTB610~ SVCAD>D02746034~ DTM47220190324~ CASCO13126~ AMTB634~ SVCAD>D11107349~ DTM47220190324~ CASCO13124~ AMTB649~ SE3535681~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 120/128 Example 4: Claim Adjustment Reason Code 45 ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI80.00CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLPPATACCT140080MCCLAIMNUMBER111~ NM1QC1DOEJOHNN*MIABC123456789~ REF1L12345F~ DTM05020190209~ PERCXG CUSTOMER SERVICE DEPARTMENTTE8004074627~ AMTAU150~ SVCHC>99213150801~ DTM47220190101~ CASCO4570~ AMTB680~ SVCHC>8500310001~ DTM47220190101~ CASCO204100~ SVCHC>3641515001~ DTM47220190101~ CASCO97150~ SE3310060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 121/128 Example 5a: Line Service Tax impacting payment only ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI11.06CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLPPCN136.2011.0612CLAIMNUMB111~ NM1QC1LASTFIRSTJ*MI123456789~ NM1821*****XX1447481825~ MOA**N25~ REF1L102345~ REFEA065789~ DTM05020170113~ AMTAU36.20~ SVCHC>9921426.23.06~ DTM47220170109~ CASCO4523.2137-.06~ REF6RB1~ AMTB63~ SVCHC>36415108~ DTM47220170109~ CASCO452~ REF6RB2~ AMTB68~ SE3510060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 122/128 Example 5b: Line Service Bonuses impacting payment only ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI12.00CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLPPCN125121012CLAIMNUMB111~ NM1QC1LASTFIRSTJ*MI123456789~ NM1821*****XX1447481825~ MOA**N25~ REF1L102345~ REFEA065789~ DTM05020170113~ AMTAU25~ SVCHC>992142512~ DTM47220170109~ CASCO455161-2~ CASPR310~ REF6R123~ AMTB620~ SE3110060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 123/128 Example 5c: Line Service Penalty impacting payment only ISA00* 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI8.00CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLPPCN12581012CLAIMNUMB111~ NM1QC1LASTFIRSTJ*MI123456789~ NM1821*****XX1447481825~ MOA**N25~ REF1L102345~ REFEA065789~ DTM05020170113~ AMTAU25~ SVCHC>99214258~ DTM47220170109~ CASCO455B42~ CASPR310~ REF6R123~ AMTB620~ SE3110060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 124/128 Example 6: Not Covered/Not Authorized Inpatient Facility claim days ISA00* 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI8000.00CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLPPATACCT1400008000MCCLAIMNUMBER111~ CASCO197200014530000~ NM1QC1DOEJOHNN*MIABC123456789~ REF1L12345F~ DTM23220190101~ DTM23320190105~ DTM05020190209~ PERCXG CUSTOMER SERVICE DEPARTMENTTE8004001212~ AMTAU38000~ QTYCA4~ SE2710060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 125/128 Example 8a: Claim submitted with incorrect subscriber as patient and incorrect ID ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI120.03CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLP04777796TLC7771221155120.03138838888212111~ NM1QC1MASTERSMARVINL*MI80444444403~ NM1IL1CABLEMABEL***MI80444444403~ NM1741MASTERSMARVIN***C80444444401~ NM1821SHELTON MDBLAKE***XX1666666666~ REF1L28~ REFCEHSOAP-LAOA~ DTM23220191114~ DTM23320181114~ DTM05020181119~ AMTAU155~ SVCHC>99393155120.031~ DTM47220181114~ CASCO4534.97~ REFLU11~ REF6R22261822~ AMTB6120.03~ SE3410060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 126/128 Example 8b: Claim submitted with incorrect subscriber name and ID ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI35.06CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLP02333TLC222222111535.0635138333333214111~ NM1QC1KEATONALEXP*MI80000006006~ NM1IL1THOMASJASON***MI80000006006~ NM1741JEROME*C80000006001~ NM1821BLOOD MDRED N***XX1888888886~ REF1L28~ REFCEOAPOS-LAOA~ DTM23220191113~ DTM23320191113~ DTM05020191119~ AMTAU115~ SVCHC>9921311535.061~ DTM47220191113~ CASCO4544.94~ CASPR335~ REFLU11~ REF6R22261389~ AMTB670.06~ SE3510060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 127/128 Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation. Example 8c: Claim submitted with for subscriber missing the Middle initial ISA00* 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI2415.25CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLP05444444TLC999999139032415.25138777777782211~ NM1QC1GONZALESSAMMY***MI80455555502~ NM1IL1LAPLANTEFERN***MI80455555502~ NM1741**R~ NM1821GOOD MDROBERT B**XX19999999987~ REF1L28~ REFCEOAPOS-LAOA~ DTM23220191101~ DTM23320191101~ DTM05020191114~ AMTAU3903~ AMTF5150~ SVCHC>5940039032415.251~ DTM47220191101~ CASCO451487.75~ REFLU21~ REF6R22215592~ AMTB62415.25~ SE3510060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 128/128	X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation. Example 8c: Claim submitted with for subscriber missing the Middle initial ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI2415.25CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ DTM40520190827~ N1PRANY PLAN USA~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8661112222~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLP05444444TLC999999139032415.25138777777782211~ NM1QC1GONZALESSAMMY***MI80455555502~ NM1IL1LAPLANTEFERN***MI80455555502~ NM1741**R~ NM1821GOOD MDROBERT B**XX19999999987~ REF1L28~ REFCEOAPOS-LAOA~ DTM23220191101~ DTM23320191101~ DTM05020191114~ AMTAU3903~ AMTF5150~ SVCHC>5940039032415.251~ DTM47220191101~ CASCO451487.75~ REFLU21~ REF6R22215592~ AMTB62415.25~ SE3510060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 128/128	X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
Stedi maintains this guide based on public documentation from Health Partner Plans. Contact Health Partner Plans for official EDI specifications. To report any errors in this guide, please contact us. X12 835 Health Care Claim Payment/Advice (X221A1) X12 Release 5010 Revised February 22, 2024 Go to Stedi Network 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 View the latest version of this implementation guide as an interactive webpage https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim- paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K POWERED BY Build EDI implementation guides at stedi.com 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 1/82 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 REF 0600 Receiver Identification Max use 1 Optional Payer Identification Loop N1 0800 Payer Identification Max use 1 Required N3 1000 Payer Address Max use 1 Required N4 1100 Payer City, State, ZIP Code Max use 1 Required PER 1300 Payers Claim Office Max use 1 Optional PER 1300 Technical Department Max use 1 Required PER 1300 Uniform Resource Locator (URL) Max use 1 Optional Payee Identification Loop N1 0800 Payee Identification Max use 1 Required N3 1000 Payee Address Max use 1 Optional N4 1100 Payee City, State, ZIP Code Max use 1 Optional REF 1200 Federal Taxpayer's Identification Number Max use 1 Optional REF 1200 Payee Identification Max use 1 Optional RDM 1400 Remittance Delivery Method Max use 1 Optional Detail Header Number Loop LX 0030 Header Number Max use 1 Required Claim Payment Information Loop CLP 0100 Claim Payment Information Max use 1 Required 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 2/82 CAS 0200 Claim Adjustment Max use 99 Optional NM1 0300 Other Insured Max use 1 Optional NM1 0300 Patient Name Max use 1 Required NM1 0300 Service Provider Name Max use 1 Optional DTM 0500 Claim Received Date Max use 1 Optional DTM 0500 Coverage Expiration Date Max use 1 Optional AMT 0620 Claim Supplemental Information Max use 13 Optional Service Payment Information Loop SVC 0700 Service Payment Information Max use 1 Required DTM 0800 Service Date Max use 2 Optional CAS 0900 Service Adjustment Max use 99 Optional REF 1000 Line Item Control Number Max use 1 Optional REF 1000 Rendering Provider Information Max use 10 Optional REF 1000 Service Identification Max use 8 Optional AMT 1100 Service Supplemental Amount Max use 9 Optional LQ 1300 Health Care Remark Codes Max use 99 Optional Summary PLB 0100 Provider Adjustment Max use 1 Optional SE 0200 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 3/82 ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange- related control segments Example ISA00 00 XXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXX2501300825^0050100000000 0XX>~ Max use 1 Required ISA-01 I01 Authorization Information Qualifier Identifier (ID) 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 Min 10 Max 10 String (AN) Required 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 Identifier (ID) 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 Min 10 Max 10 String (AN) Required 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 Min 2 Max 2 Identifier (ID) Required 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 Min 15 Max 15 String (AN) Required 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 4/82 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 Min 2 Max 2 Identifier (ID) Required 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 Min 15 Max 15 String (AN) Required 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 YYMMDD format Date (DT) Required Date of the interchange ISA-10 I09 Interchange Time HHMM format Time (TM) Required Time of the interchange ISA-11 I65 Repetition Separator Min 1 Max 1 String (AN) Required 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 Identifier (ID) 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 Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender ISA-14 I13 Acknowledgment Requested Min 1 Max 1 Identifier (ID) Required 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 5/82 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 Min 1 Max 1 Identifier (ID) Required 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 Min 1 Max 1 String (AN) Required 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 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 6/82 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GSHPXXXXXX202501301226000X005010X221A1~ Max use 1 Required GS-01 479 Functional Identifier Code Identifier (ID) Required Code identifying a group of application related transaction sets HP Health Care Claim Payment/Advice (835) GS-02 142 Application Sender's Code Min 2 Max 15 String (AN) Required Code identifying party sending transmission; codes agreed to by trading partners GS-03 124 Application Receiver's Code Min 2 Max 15 String (AN) Required Code identifying party receiving transmission; codes agreed to by trading partners GS-04 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year GS-05 337 Time HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time (TM) Required 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 Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480 T Transportation Data Coordinating Committee (TDCC) 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 7/82 X Accredited Standards Committee X12 GS-08 480 Version / Release / Industry Identifier Code String (AN) 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 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 8/82 Heading ST 0100 Heading > ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST8350001~ Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) 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 Min 4 Max 9 Numeric (N) Required 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. 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 9/82 BPR 0200 Heading > BPR Financial Information To indicate the beginning of a Payment Order/Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and/or information from payer to payee to occur 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 BPRI0000000000000CCHK************20250130~ Max use 1 Required BPR-01 305 Transaction Handling Code Identifier (ID) Required Code designating the action to be taken by all parties I Remittance Information Only Use this code to indicate to the payee that the remittance detail is moving separately from the payment. BPR-02 782 Total Actual Provider Payment Amount Decimal number (R) Required Min 1 Max 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 Identifier (ID) 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	Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 8/82 Heading ST 0100 Heading > ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST8350001~ Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) 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 Min 4 Max 9 Numeric (N) Required 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. 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 9/82 BPR 0200 Heading > BPR Financial Information To indicate the beginning of a Payment Order/Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and/or information from payer to payee to occur 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 BPRI0000000000000CCHK***********20250130~ Max use 1 Required BPR-01 305 Transaction Handling Code Identifier (ID) Required Code designating the action to be taken by all parties I Remittance Information Only Use this code to indicate to the payee that the remittance detail is moving separately from the payment. BPR-02 782 Total Actual Provider Payment Amount Decimal number (R) Required Min 1 Max 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 Identifier (ID) 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. BPR-04 591 Payment Method Code Identifier (ID) Required Code identifying the method for the movement of payment instructions 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 10/82 CHK Check Use this code to indicate that a check has been issued for payment. BPR-16 373 Check Issue or EFT Effective Date CCYYMMDD format Date (DT) Required 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. 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 11/82 TRN 0400 Heading > TRN Reassociation Trace Number 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 TRN1XXXXXXXXXXXX~ Max use 1 Required TRN-01 481 Trace Type Code Identifier (ID) Required Code identifying which transaction is being referenced 1 Current Transaction Trace Numbers TRN-02 127 Check or EFT Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 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. Check Number TRN-03 509 Payer Identifier Min 10 Max 10 String (AN) Required 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). 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 12/82 REF 0600 Heading > REF Receiver Identification 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 REFEVXX~ Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EV Receiver Identification Number REF-02 127 Receiver Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Receiver Identification Number 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 13/82 1000A Payer Identification Loop Max 1 Required Variants (all may be used) Payee Identification Loop N1 0800 Heading > Payer Identification Loop > N1 Payer Identification 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 N1PRHealth Partners of Philadelphia~ Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer N1-02 93 Payer Name String (AN) Required Free-form name Health Partners of Philadelphia 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 14/82 N3 1000 Heading > Payer Identification Loop > N3 Payer Address To specify the location of the named party Example N3901 Market StSuite 500~ Max use 1 Required N3-01 166 Payer Address Line String (AN) Required Address information 901 Market St N3-02 166 Payer Address Line String (AN) Optional Address information Suite 500 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 15/82 N4 1100 Heading > Payer Identification Loop > N4 Payer City, State, ZIP Code To specify the geographic place of the named party Example N4PhiladelphiaPA19107XXX~ 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 Max use 1 Required N4-01 19 Payer City Name String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. Philadelphia N4-02 156 Payer State Code Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. PA N4-03 116 Payer Postal Zone or ZIP Code Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) 19107 N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 16/82 Use the country subdivision codes from Part 2 of ISO 3166. 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 17/82 PER 1300 Heading > Payer Identification Loop > PER Payers Claim Office 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 PERCXClaim DepartmentTE2159914350TEXXXEXX X~ Variants (all may be used) PER Technical Department PER Uniform Resource Locator (URL) 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 Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Payer Contact Name String (AN) Optional 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). Claim Department PER-03 365 Communication Number Qualifier Identifier (ID) Optional 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 18/82 Code identifying the type of communication number TE Telephone PER-04 364 Payer Contact Communication Number String (AN) Optional Complete communications number including country or area code when applicable 2159914350 PER-05 365 Communication Number Qualifier Identifier (ID) 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 Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM Health Partner	Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
Code identifying the country subdivision Usage notes 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 16/82 Use the country subdivision codes from Part 2 of ISO 3166. 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 17/82 PER 1300 Heading > Payer Identification Loop > PER Payers Claim Office 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 PERCXClaim DepartmentTE2159914350TEXXXEXX X~ Variants (all may be used) PER Technical Department PER Uniform Resource Locator (URL) 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 Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Payer Contact Name String (AN) Optional 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). Claim Department PER-03 365 Communication Number Qualifier Identifier (ID) Optional 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 18/82 Code identifying the type of communication number TE Telephone PER-04 364 Payer Contact Communication Number String (AN) Optional Complete communications number including country or area code when applicable 2159914350 PER-05 365 Communication Number Qualifier Identifier (ID) 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 Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 19/82 PER 1300 Heading > Payer Identification Loop > PER Technical Department 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 PERBLEDI SupportTE2159914290EMEDI@HEALTHPAR T.COMFXXXXX~ Variants (all may be used) PER Payers Claim Office PER Uniform Resource Locator (URL) 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 Max use 1 Required PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named BL Technical Department PER-02 93 Payer Technical Contact Name String (AN) Optional 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). EDI Support PER-03 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number TE Telephone Recommended PER-04 364 Payer Contact Communication Number String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 20/82 2159914290 PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail PER-06 364 Payer Technical Contact Communication Number String (AN) Optional Complete communications number including country or area code when applicable [email protected] PER-07 365 Communication Number Qualifier Identifier (ID) 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 Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 21/82 1000A Payer Identification Loop end PER 1300 Heading > Payer Identification Loop > PER Uniform Resource Locator (URL) 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 PERICURwww.healthpart.com~ Variants (all may be used) PER Payers Claim Office PER Technical Department Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number UR Uniform Resource Locator (URL) PER-04 364 Communication Number String (AN) Required 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. www.healthpart.com 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 22/82 1000B Payee Identification Loop Max 1 Required Variants (all may be used) Payer Identification Loop N1 0800 Heading > Payee Identification Loop > N1 Payee Identification 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 N1PEXXXXXXXXX~ Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PE Payee N1-02 93 Payee Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) 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. 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 Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 23/82 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. 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 24/82 N3 1000 Heading > Payee Identification Loop > N3 Payee Address 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. Situational (when needed to inform Receiver of Payee Address) Example N3XXXXXXXXX~ Max use 1 Optional N3-01 166 Payee Address Line Min 1 Max 55 String (AN) Required Address information Usage notes Payee Address Information provided to Health Partners N3-02 166 Payee Address Line Min 1 Max 55 String (AN) Optional Address information Usage notes Payee Address Information, if second line needed 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 25/82 N4 1100 Heading > Payee Identification Loop > N4 Payee City, State, ZIP Code 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. Situational (when needed to inform Receiver) Example N4XXXXXXXXXXXXXXXXXXX~ 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 Max use 1 Optional N4-01 19 Payee City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. Usage notes Payee City Name provided N4-02 156 Payee State Code Min 2 Max 2 Identifier (ID) Optional 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. Usage notes Payee State Name provided N4-03 116 Payee Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes Payee Zip Code provided N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 26/82 Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 27/82 REF 1200 Heading > Payee Identification Loop > REF Federal Taxpayer's Identification Number 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. Situational (When additional identification is needed) Example REFTJXXXXXX~ Variants (all may be used) REF Payee Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification TJ Federal Taxpayer's Identification Number REF-02 127 Additional Payee Identifier Min 1 Max 30 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Federal Taxpayer Identification Number 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 28/82 REF 1200 Heading > Payee Identification Loop > REF Payee Identification 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. Situational (When additional identification is needed) Example REFPQX~ Variants (all may be used) REF Federal Taxpayer's Identification Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PQ Payee Identification REF-02 127	Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
be provided at the sender's discretion, but cannot be required by the receiver. Situational (when needed to inform Receiver) Example N4XXXXXXXXXXXXXXXXXXX~ 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 Max use 1 Optional N4-01 19 Payee City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. Usage notes Payee City Name provided N4-02 156 Payee State Code Min 2 Max 2 Identifier (ID) Optional 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. Usage notes Payee State Name provided N4-03 116 Payee Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes Payee Zip Code provided N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 26/82 Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 27/82 REF 1200 Heading > Payee Identification Loop > REF Federal Taxpayer's Identification Number 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. Situational (When additional identification is needed) Example REFTJXXXXXX~ Variants (all may be used) REF Payee Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification TJ Federal Taxpayer's Identification Number REF-02 127 Additional Payee Identifier Min 1 Max 30 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Federal Taxpayer Identification Number 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 28/82 REF 1200 Heading > Payee Identification Loop > REF Payee Identification 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. Situational (When additional identification is needed) Example REFPQX~ Variants (all may be used) REF Federal Taxpayer's Identification Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PQ Payee Identification REF-02 127 Additional Payee Identifier Min 1 Max 30 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Health Partners Legacy Number 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 29/82 RDM 1400 Heading > Payee Identification Loop > RDM Remittance Delivery Method 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 RDMBMXXXXXXX~ Max use 1 Optional RDM-01 756 Report Transmission Code Identifier (ID) 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 Min 1 Max 60 String (AN) Optional 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 Min 1 Max 256 String (AN) Optional 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 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 30/82 1000B Payee Identification Loop end Heading end Contains URL web address or e-mail address. 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 31/82 Detail 2000 Header Number Loop Max >1 Optional LX 0030 Detail > Header Number Loop > LX Header Number 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 LX00000~ Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 32/82 2100 Claim Payment Information Loop Max >1 Required CLP 0100 Detail > Header Number Loop > Claim Payment Information Loop > CLP Claim Payment Information 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 CLPXX20000000000000000000HMXXXXXXXX00 0~ Max use 1 Required CLP-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required 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 Identifier (ID) 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. Claim Status. See page 124 of HIPAA TR3 for valid codes 1 Processed as Primary Use this code if the claim was adjudicated by the current payer as primary regardless of whether any part of the claim was paid. 2 Processed as Secondary Use this code if the claim was adjudicated by the current payer as secondary regardless of whether any part of the claim was paid. 3 Processed as Tertiary Use this code if the claim was adjudicated by the current payer as tertiary (or subsequent) regardless of whether any part of the claim was paid. 4 Denied 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 33/82 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 Min 1 Max 15 Decimal number (R) Required 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 Min 1 Max 15 Decimal number (R) Required Monetary amount CLP04 is the amount paid this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. See section 1.10.2.9 for information about interest considerations. Use this monetary amount for the amount paid for this claim. It can be positive, zero or negative, but the value in BPR02 may not be negative. CLP-05 782 Patient Responsibility Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CLP05 is the patient responsibility amount. Usage notes 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 34/82 Amounts in CLP05 must have supporting adjustments reflected in CAS segments at the 2100 (CLP) or 2110 (SVC) loop level with a Claim Adjustment Group (CAS01) code of PR (Patient Responsibility). Use this monetary amount for the payer's statement of the patient responsibility amount for this claim, which can include such items as deductible, non-covered services, co-pay and co-insurance. This is not used for reversals. See section 1.10.2.8, Reversals and Corrections, for additional information. CLP-06 1032 Claim Filing Indicator Code Identifier (ID) Required 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	Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
Decimal number (R) Required 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 Min 1 Max 15 Decimal number (R) Required Monetary amount CLP04 is the amount paid this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. See section 1.10.2.9 for information about interest considerations. Use this monetary amount for the amount paid for this claim. It can be positive, zero or negative, but the value in BPR02 may not be negative. CLP-05 782 Patient Responsibility Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CLP05 is the patient responsibility amount. Usage notes 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 34/82 Amounts in CLP05 must have supporting adjustments reflected in CAS segments at the 2100 (CLP) or 2110 (SVC) loop level with a Claim Adjustment Group (CAS01) code of PR (Patient Responsibility). Use this monetary amount for the payer's statement of the patient responsibility amount for this claim, which can include such items as deductible, non-covered services, co-pay and co-insurance. This is not used for reversals. See section 1.10.2.8, Reversals and Corrections, for additional information. CLP-06 1032 Claim Filing Indicator Code Identifier (ID) Required 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. HM Health Maintenance Organization CLP-07 127 Payer Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CLP07 is the payer's internal control number. Usage notes Use this number for the payer's internal control number. This number must apply to the entire claim. CLP-08 1331 Facility Type Code Min 1 Max 2 String (AN) Optional Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. Usage notes Since professional or dental claims can have different place of service codes for services within a single claim, default to the place of service of the first service line 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 35/82 when the service lines are not all for the same place of service. This number was received in CLM05-1 of the 837 claim. CLP-09 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Optional Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type Usage notes This number was received in CLM05-3 of the 837 Claim. CLP-11 1354 Diagnosis Related Group (DRG) Code Min 1 Max 4 Identifier (ID) Optional Code indicating a patient's diagnosis group based on a patient's illness, diseases, and medical problems Usage notes Code Source 229. Institutional claims only. CLP-12 380 Diagnosis Related Group (DRG) Weight Decimal number (R) Optional Min 1 Max 15 Numeric value of quantity CLP12 is the diagnosis-related group (DRG) weight. Usage notes This is the adjudicated DRG Weight. 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 36/82 CAS 0200 Detail > Header Number Loop > Claim Payment Information Loop > CAS Claim Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Payers must use this CAS segment to report claim level adjustments that cause the amount paid to differ from the amount originally charged. See 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. See the SVC TR3 Note #1 for details about per diem adjustments. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment must be the first non-zero adjustment and is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Required when dollar amounts and/or quantities are being adjusted at the claim level. If not required by this implementation guide, do not send. Example CASPIXXX0000000000000000000000~ Max use 99 Optional CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer/payee contractual agreement or a regulatory requirement resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. 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 Min 1 Max 5 Identifier (ID) Required 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 37/82 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. Code Source 139: Claim Adjustment Reason Code CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. Claim Level Adjustment Amount CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes See section 1.10.2.4.1 for additional information. A positive value decreases the covered days, and a negative number increases the covered days. Provided only when unit quantity is being adjusted 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 38/82 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Other Insured 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 NM1GB2XXXXXXXXXXXXXFIXXXXX~ Variants (all may be used) NM1 Patient Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Other Subscriber Identifier (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual GB Other Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Subscriber Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name Usage notes At least one of NM103 or NM109 must be present. NM1-04 1036 Other Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 39/82 Individual middle name or initial Usage notes When only one character is present this is assumed to be the middle initial. NM1-07 1039 Other Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Not Used when NM102=1. II Standard Unique Health Identifier for each Individual in the United States Use this code if mandated in a final Federal Rule. MI Member Identification Number Use this code when supplying the number used for identification of the subscriber in NM109. NM1-09 67 Other Subscriber Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes At least one of NM103 or NM109 must be present. 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 40/82 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Patient Name To supply the full name of an individual or organizational entity Usage notes Provide the patient's identification number in NM109. This segment must provide the information from the original claim. For example, when the claim is submitted as an ASC X12 837 transaction, this is the 2010CA loop NM1 Patient Name Segment unless not present on the original claim, then it is the 2010BA loop NM1 Subscriber name segment. The Corrected Patient/Insured Name NM1 segment identifies the adjudicated Insured Name and ID information if different than what was submitted on the claim. Example NM1QC1XXXXXXXXXX**MIXXXXX~ Variants (all may be used) NM1 Other Insured NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Patient Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual QC Patient NM1-02 1065	Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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 NM1GB2XXXXXXXXXXXXXFIXXXXX~ Variants (all may be used) NM1 Patient Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Other Subscriber Identifier (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual GB Other Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Subscriber Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name Usage notes At least one of NM103 or NM109 must be present. NM1-04 1036 Other Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 39/82 Individual middle name or initial Usage notes When only one character is present this is assumed to be the middle initial. NM1-07 1039 Other Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Not Used when NM102=1. II Standard Unique Health Identifier for each Individual in the United States Use this code if mandated in a final Federal Rule. MI Member Identification Number Use this code when supplying the number used for identification of the subscriber in NM109. NM1-09 67 Other Subscriber Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes At least one of NM103 or NM109 must be present. 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 40/82 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Patient Name To supply the full name of an individual or organizational entity Usage notes Provide the patient's identification number in NM109. This segment must provide the information from the original claim. For example, when the claim is submitted as an ASC X12 837 transaction, this is the 2010CA loop NM1 Patient Name Segment unless not present on the original claim, then it is the 2010BA loop NM1 Subscriber name segment. The Corrected Patient/Insured Name NM1 segment identifies the adjudicated Insured Name and ID information if different than what was submitted on the claim. Example NM1QC1XXXXXXXXXX**MIXXXXX~ Variants (all may be used) NM1 Other Insured NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Patient Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual QC Patient NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Patient Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Patient First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Patient Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 41/82 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) MI Member Identification Number NM1-09 67 Patient Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 42/82 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Service Provider Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the rendering provider. An identification number is provided in NM109. This information is provided to facilitate identification of the claim within a payee's system. Other providers (e.g., Referring provider, supervising provider) related to the claim but not directly related to the payment are not supported and are not necessary for claim identification. Required when the rendering provider is different from the payee. If not required by this implementation guide, do not send. Example NM1821XXX***XXXXX~ Variants (all may be used) NM1 Other Insured NM1 Patient Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Name Last or Organization Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Name First Min 1 Max 35 String (AN) Optional Individual first name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 43/82 XX Centers for Medicare and Medicaid Services National Provider Identifier Required value if the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate. Otherwise, one of the other listed codes may be used. NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes National Provider Identifier Number Provided 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 44/82 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Claim Received Date To specify pertinent dates and times Usage notes Required whenever state or federal regulations or the provider contract mandate interest payment or prompt payment discounts based upon the receipt date of the claim by the payer. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example DTM05020250130~ Variants (all may be used) DTM Coverage Expiration Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the date that the claim was received by the payer. 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 45/82 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Coverage Expiration Date To specify pertinent dates and times Usage notes Required when payment is denied because of the expiration of coverage. If not required by this implementation guide, do not send. Situational (Required due to expiration of coverage) Example DTM03620250130~ Variants (all may be used) DTM Claim Received Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 036 Expiration DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the expiration date of the patient's coverage. 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 46/82 AMT 0620 Detail > Header Number Loop > Claim Payment Information Loop > AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send/receive one AMT for each applicable non-zero value. Do not report any zero values. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTD8000~ Max use 13 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount D8 Discount Amount Prompt Pay Discount Amount See section 1.10.2.9 for additional information. I Interest See section 1.10.2.9 for additional information. T Tax AMT-02 782 Claim Supplemental Information Amount Decimal number (R) Required Min 1 Max 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. 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 47/82 2110 Service Payment Information Loop Max 999 Optional SVC 0700 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > SVC Service Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO7825~). See section 1.10.2.4.1 for additional information. See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information. Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send. Example SVCNU>XXX>XX>XX>XX>XX0000000000000000000000*0 00ER>X*000000000~ Max use 1 Required SVC-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132). Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7. See HIPAA 835 Technical Report Type 3, pg. 187-188 for supported codes AD American Dental Association Codes ER Jurisdiction Specific Procedure and Supply Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 48/82 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	Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO7825~). See section 1.10.2.4.1 for additional information. See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information. Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send. Example SVCNU>XXX>XX>XX>XX>XX0000000000000000000000*0 00ER>X000000000~ Max use 1 Required SVC-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132). Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7. See HIPAA 835 Technical Report Type 3, pg. 187-188 for supported codes AD American Dental Association Codes ER Jurisdiction Specific Procedure and Supply Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 48/82 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 Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 49/82 C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. SVC-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC02 is the submitted service charge. Usage notes Use this monetary amount for the submitted service charge amount. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. SVC-03 782 Line Item Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC03 is the amount paid this service. Usage notes Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. See 1.10.2.1, Balancing, for additional information. SVC-05 380 Units of Service Paid Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC05 is the paid units of service. Usage notes If not present, the value is assumed to be one. SVC-06 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC06 is the original submitted medical procedure. Usage notes Max use 1 Optional 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 50/82 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 Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7. Provided if procedure code in SVC01 is different from procedure code submitted; see pg. 191 of the HIPAA Technical Report Type 3 AD American Dental Association Codes ER Jurisdiction Specific Procedure and Supply Codes HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. IV Home Infusion EDI Coalition (HIEC) Product/Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property & Casualty claims/encounters that are not covered under HIPAA. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes WK Advanced Billing Concepts (ABC) Codes This qualifier can only be used in transactions covere under HIPAA by parties registered in the pilot project and their trading partners. C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. SVC-07 380 Original Units of Service Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC07 is the original submitted units of service. Usage notes 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 51/82 Only provided when paid unit is different from submitted units 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 52/82 DTM 0800 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > DTM Service Date To specify pertinent dates and times Usage notes Dates at the service line level apply only to the service line where they appear. If used for inpatient claims and no service date was provided on the claim then report the through date from the claim level. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. Required when claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. For retail pharmacy claims, the service date is equivalent to the prescription filled date. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM15120250130~ Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 150 Service Period Start This qualifier is required for reporting the beginning of multi-day services. If not required by this implementation guide, do not send. 151 Service Period End This qualifier is required for reporting the end of multi-day services. If not required by this implementation guide, do not send. 472 Service This qualifier is required to indicate a single day service. If not required by this implementation guide, do not send. DTM-02 373 Service Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 53/82 CAS 0900 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > CAS Service Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes An example of this level of CAS is the reduction for the part of the service charge that exceeds the usual and customary charge for the service. See sections 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02). If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Situational (to account for difference in amount paid for this service) Example CASCOXXXX0000000*00000000000000~ Max use 99 Optional	Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
dates for individual service lines. Required when claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. For retail pharmacy claims, the service date is equivalent to the prescription filled date. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM15120250130~ Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 150 Service Period Start This qualifier is required for reporting the beginning of multi-day services. If not required by this implementation guide, do not send. 151 Service Period End This qualifier is required for reporting the end of multi-day services. If not required by this implementation guide, do not send. 472 Service This qualifier is required to indicate a single day service. If not required by this implementation guide, do not send. DTM-02 373 Service Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 53/82 CAS 0900 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > CAS Service Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes An example of this level of CAS is the reduction for the part of the service charge that exceeds the usual and customary charge for the service. See sections 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02). If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Situational (to account for difference in amount paid for this service) Example CASCOXXXX000000000000000000000~ Max use 99 Optional CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer/payee agreement or a regulatory requirement has resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. 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 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 54/82 CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01. Code Source 139: Claim Adjustment Reason Code CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03 and CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes A positive number decreases paid units, and a negative value increases paid units. 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 55/82 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Line Item Control Number To specify identifying information Usage notes This is the Line Item Control Number submitted in the 837, which is utilized by the provider for tracking purposes. See section 1.10.2.11 and 1.10.2.14.1 for additional information on usage with split claims or services. Note - the value in REF02 can include alpha characters. Required when a Line Item Control Number was received on the original claim or when claim or service line splitting has occurred. If not required by this implementation guide, do not send. Example REF6RXX~ Variants (all may be used) REF Rendering Provider Information REF Service Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 56/82 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Rendering Provider Information To specify identifying information Usage notes Required when the rendering provider for this service is different than the rendering provider applicable at the claim level. If not required by this implementation guide, do not send. Example REFTJXXXX~ Variants (all may be used) REF Line Item Control Number REF Service Identification Max use 10 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification HPI Centers for Medicare and Medicaid Services National Provider Identifier This qualifier is REQUIRED when the National Provider Identifier is mandated for use and the provider is a covered health care provider under that mandate. TJ Federal Taxpayer's Identification Number REF-02 127 Rendering Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 57/82 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Service Identification To specify identifying information Usage notes Required when related service specific reference identifiers were used in the process of adjudicating this service. If not required by this implementation guide, do not send. Example REFAPCXX~ Variants (all may be used) REF Line Item Control Number REF Rendering Provider Information Max use 8 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1S Ambulatory Patient Group (APG) Number APC Ambulatory Payment Classification 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 Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 58/82 AMT 1100 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > AMT Service Supplemental Amount To indicate the total monetary amount Usage notes This segment is used to convey information only. It is not part of the financial balancing of the 835. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTZK00000000000~ Max use 9 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount B6 Allowed - Actual Allowed amount is the amount the payer deems payable prior to considering patient responsibility. KH Deduction Amount Late Filing Reduction 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 Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. Corresponding Amount (Service Line Allowed Amount) 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 59/82 2110 Service Payment Information Loop end 2100 Claim Payment Information Loop end 2000 Header Number Loop end Detail end LQ 1300 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > LQ Health Care Remark Codes To identify standard industry codes Usage notes Use this segment to provide informational remarks only. This segment has no impact on the actual payment. Changes in claim payment amounts are provided in the CAS segments. Required when remark codes or NCPDP Reject/Payment codes are necessary for the provider to fully understand the adjudication message for a given service line. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example LQHEXXX~ Max use 99 Optional LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list HE Claim Payment Remark Codes LQ-02 1271 Remark Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 60/82 Summary PLB 0100 Summary > PLB Provider Adjustment To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service Usage notes These adjustments can either decrease the payment (a positive number) or increase the payment (a negative number). Zero dollar adjustments are not allowed. Some examples of PLB adjustments are a Periodic Interim Payment (loans and loan repayment) or a capitation payment. Multiple adjustments can be placed in one PLB segment, grouped by the provider identified in PLB01 and the period identified in PLB02. Although the PLB reference numbers are not standardized, refer to 1.10.2.9 (Interest and Prompt Payment Discounts), 1.10.2.10 (Capitation and Related Payments or Adjustments), 1.10.2.12 (Balance Forward Processing), 1.10.2.16 (Post Payment Recovery)	Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
Identifier (ID) Required Code to qualify amount B6 Allowed - Actual Allowed amount is the amount the payer deems payable prior to considering patient responsibility. KH Deduction Amount Late Filing Reduction 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 Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. Corresponding Amount (Service Line Allowed Amount) 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 59/82 2110 Service Payment Information Loop end 2100 Claim Payment Information Loop end 2000 Header Number Loop end Detail end LQ 1300 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > LQ Health Care Remark Codes To identify standard industry codes Usage notes Use this segment to provide informational remarks only. This segment has no impact on the actual payment. Changes in claim payment amounts are provided in the CAS segments. Required when remark codes or NCPDP Reject/Payment codes are necessary for the provider to fully understand the adjudication message for a given service line. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example LQHEXXX~ Max use 99 Optional LQ-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list HE Claim Payment Remark Codes LQ-02 1271 Remark Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 60/82 Summary PLB 0100 Summary > PLB Provider Adjustment To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service Usage notes These adjustments can either decrease the payment (a positive number) or increase the payment (a negative number). Zero dollar adjustments are not allowed. Some examples of PLB adjustments are a Periodic Interim Payment (loans and loan repayment) or a capitation payment. Multiple adjustments can be placed in one PLB segment, grouped by the provider identified in PLB01 and the period identified in PLB02. Although the PLB reference numbers are not standardized, refer to 1.10.2.9 (Interest and Prompt Payment Discounts), 1.10.2.10 (Capitation and Related Payments or Adjustments), 1.10.2.12 (Balance Forward Processing), 1.10.2.16 (Post Payment Recovery) and 1.10.2.17 (Claim Overpayment Recovery) for code suggestions and usage guidelines. The codes and notations under PLB03 and its components apply equally to PLB05, 07, 09, 11 and 13. Required when reporting adjustments to the actual payment that are NOT specific to a particular claim or service. If not required by this implementation guide, do not send. Example PLBXXXXX20250130PI00000~ Max use >1 Optional PLB-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB01 is the provider number assigned by the payer. Usage notes When the National Provider Identifier (NPI) is mandated and the provider is a covered health care provider under that mandate, this must be the NPI assigned to the provider. Until the NPI is mandated, this is the provider identifier as assigned by the payer. PLB-02 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year PLB02 is the last day of the provider's fiscal year. Usage notes 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 61/82 This is the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known by the payer, use December 31st of the current year. PLB-03 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB03 is the adjustment information as defined by the payer. Max use 1 Required C042-01 426 Adjustment Reason Code Identifier (ID) Required Code indicating reason for debit or credit memo or adjustment to invoice, debit or credit memo, or payment Usage notes Refer to HIPAA Technical Report Type pg. 219-222 for supported Code Values 50 Late Charge This is the Late Claim Filing Penalty or Medicare Late Cost Report Penalty. 51 Interest Penalty Charge This is the interest assessment for late filing. 72 Authorized Return This is the provider refund adjustment. This adjustment acknowledges a refund received from a provider for previous overpayment. PLB03-2 must always contain an identifying reference number when the value is used. PLB04 must contain a negative value. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to this adjustment reason code must be directly offset. 90 Early Payment Allowance AH Origination Fee This is the claim transmission fee. This is used for transmission fees that are not specific to or dependent upon individual claims. AM Applied to Borrower's Account See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. Use this code to identify the loan repayment amount. This is capitation specific. AP Acceleration of Benefits This is the accelerated payment amount or withholding. Withholding or payment identification is indicated by the sign of the amount in PLB04. A positive value represents a withholding. A negative value represents a payment. B2 Rebate This adjustment code applies when a provider has remitted an overpayment to a health plan in excess of the amount requested by the health plan. The amount accepted by the health plan is reported using code 72 (Authorized Return) and offset by the amount with code WO (Overpayment Recovery). The excess returned by the provider is reported as a negative amount using code B2, returning the excess funds to the provider. B3 Recovery Allowance This represents the check received from the provider for overpayments generated by payments from other payers. This code differs from the provider refund adjustment identified with code 72. This adjustment must always be offset by some other PLB 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 62/82 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". 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 63/82 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). PLB-04 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Required 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. 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 64/82 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 65/82 Summary end SE 0200 Summary > SE Transaction Set Trailer To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments) Example SE00000001~ Max use 1 Required SE-01 96 Transaction Segment Count Min 1 Max 10 Numeric (N0) Required Total number of segments included in a transaction set including ST and SE segments SE-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required 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. 1/29/25, 8:52 PM Health Partner Plans 835 Health	Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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). PLB-04 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Required 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. 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 64/82 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 65/82 Summary end SE 0200 Summary > SE Transaction Set Trailer To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments) Example SE00000001~ Max use 1 Required SE-01 96 Transaction Segment Count Min 1 Max 10 Numeric (N0) Required Total number of segments included in a transaction set including ST and SE segments SE-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required 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. 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 66/82 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE0000000000~ Max use 1 Required GE-01 97 Number of Transaction Sets Included Min 1 Max 6 Numeric (N0) Required 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 Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 67/82 IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA0000000000~ Max use 1 Required IEA-01 I16 Number of Included Functional Groups Min 1 Max 5 Numeric (N0) Required A count of the number of functional groups included in an interchange IEA-02 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 68/82 EDI Samples Example 1: Dollars and Data Sent Separately ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST835112233~ BPRI1100CCHK***********20190316~ TRN1717006665551935665544~ N1PRHealth Partners of Philadelphia~ N3901 Market St~ N4PhiladelphiaPA19107~ PERBLEDI SupportTE2159914290EM[email protected]~ N1PEACME MEDICAL CENTERXX5544667733~ REFTJ777667755~ LX1~ CLP55545554441800500300HM94060555410000111~ NM1QC1BUDDWILLIAM***MI33344555510~ AMTD8800~ SVCHC>99211800500~ DTM47220190301~ CASPR1300~ AMTB6800~ CLP876543211211200600600HM9407779923000111~ NM1QC1SETTLESUSAN**MI44455666610~ AMTD81200~ SVCHC>935551200600~ DTM47220190310~ CASPR1600~ AMTB61200~ SE25112233~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 69/82 Example 2: Multiple Claims Single Check ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83535681~ BPRI810.8CCHK***********20190331~ TRN1123451512345678~ REFEVXYZ CLEARINGHOUSE~ N1PRHealth Partners of Philadelphia~ N3901 Market St~ N4PhiladelphiaPA19107~ PERBLEDI SupportTE2159914290~ N1PEBAN DDS LLCXX9999947036~ REFTJ212121212~ LX1~ CLP77223371226132HM119932404007801111~ NM1QC1DOESANDY***MISJD11112~ NM1821BANERIN***XX1811901945~ AMTD8132~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D02202514~ DTM47220190324~ CASCO4511~ AMTB614~ SVCAD>D02302210~ DTM47220190324~ CASCO4512~ AMTB610~ SVCAD>D02746034~ DTM47220190324~ CASCO4526~ AMTB634~ SVCAD>D11107349~ DTM47220190324~ CASCO4524~ AMTB649~ CLP7722337111974*HM119932404007801111~ NM1QC1DOESALLY***MISJD11111~ NM1821BANERIN***XX1811901945~ AMTD874~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D11107349~ DTM47220190324~ CASCO4524~ AMTB649~ CLP7722337122610824HM119932404007801111~ NM1QC1SMITHSALLY**MISJD11113~ NM1821BANERIN***XX1811901945~ AMTD8132~ 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 70/82 SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D0220250~ DTM47220190324~ CASPR314~ CASCO4511~ AMTB614~ SVCAD>D0230220~ DTM47220190324~ CASPR310~ CASCO4512~ AMTB610~ SVCAD>D02746034~ DTM47220190324~ CASCO4526~ AMTB634~ SVCAD>D11107349~ DTM47220190324~ CASCO4524~ AMTB649~ CLP77223371114514902HM119932404007801111~ NM1QC1SMITHSAM**MISJD11116~ NM1821BANERIN***XX1811901945~ AMTD814~ SVCAD>D02202514~ DTM47220190324~ CASCO4511~ AMTB614~ SVCAD>D27909400~ DTM47220190324~ CASPR3756~ CASCO45184~ SVCAD>D29501800~ DTM47220190324~ CASPR3146~ CASCO4534~ CLP7722337134816.844.2HM119932404007801111~ NM1QC1JONESSAM**MISJD11122~ NM1821BANERIN***XX1811901945~ AMTD828~ SVCAD>D43421250~ DTM47220190313~ CASCO45125~ SVCAD>D4381430~ DTM47220190313~ CASPR333~ CASCO4510~ SVCAD>D295018016.8~ DTM47220190313~ CASPR311.2~ CASCO45152~ AMTB628~ CLP77223371226132*HM119932404007801111~ NM1QC1JONESSALLY***MISJD11133~ 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 71/82 NM1821BANERIN***XX1811901945~ AMTD8132~ SVCAD>D01204625~ DTM47220190321~ CASCO4521~ AMTB625~ SVCAD>D02202514~ DTM47220190321~ CASCO4511~ AMTB614~ SVCAD>D02302210~ DTM47220190321~ CASCO4512~ AMTB610~ SVCAD>D02746034~ DTM47220190321~ CASCO4526~ AMTB634~ SVCAD>D11107349~ DTM47220190321~ CASCO4524~ AMTB649~ CLP77223371179108*HM119932404007801111~ NM1QC1DOESAM***MISJD99999~ NM1821BANERIN***XX1811901945~ AMTD8108~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D02746034~ DTM47220190324~ CASCO4526~ AMTB634~ SVCAD>D11107349~ DTM47220190324~ CASCO4524~ AMTB649~ CLP7722337112982*HM119932404007801111~ NM1QC1DOESUE***MISJD88888~ NM1821BANERIN***XX1811901945~ AMTD882~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D11205437~ DTM47220190324~ CASCO4517~ AMTB637~ SVCAD>D12082920~ DTM47220190324~ CASCO459~ AMTB620~ CLP77223371221144*HM119932404007801111~ NM1QC1DOEDONNA***MISJD77777~ 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 72/82 NM1821BANERIN***XX1811901945~ AMTD8144~ SVCAD>D01204625~ DTM47220190324~ CASCO4521~ AMTB625~ SVCAD>D03309262~ DTM47220190324~ CASCO4530~ AMTB662~ SVCAD>D11205437~ DTM47220190324~ CASCO4517~ AMTB637~ SVCAD>D12082920~ DTM47220190324~ CASCO459~ AMTB620~ SE18235681~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 73/82 Example 3: Claim Specific Negotiated Discount ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83535681~ BPRI132CCHK***********20190331~ TRN1123451512345678~ REFEVCLEARINGHOUSE~ N1PRHealth Partners of Philadelphia~ N3901 Market St~ N4PhiladelphiaPA19107~ PERBLEDI SupportTE2159914290~ N1PEBAN DDS LLCFI999994703~ LX1~ CLP77223371226132HM119932404007801~ NM1QC1DOESALLY***MISJD11111~ NM1821BANERIN***XX1811901945~ AMTD8132~ SVCAD>D01204625~ DTM47220190324~ CASCO13121~ AMTB625~ SVCAD>D02202514~ DTM47220190324~ CASCO13111~ AMTB614~ SVCAD>D02302210~ DTM47220190324~ CASCO13112~ AMTB610~ SVCAD>D02746034~ DTM47220190324~ CASCO13126~ AMTB634~ SVCAD>D11107349~ DTM47220190324~ CASCO13124~ AMTB649~ SE3535681~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 74/82 Example 4: Claim Adjustment Reason Code 45 ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI80.00CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ N1PRHealth Partners of Philadelphia~ N3901 Market St~ N4PhiladelphiaPA19107~ PERCXTE2159914350~ PERBLEDI SupportTE2159914290EM[email protected]~ PERICURwww.healthpart.com~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLPPATACCT140080HMCLAIMNUMBER111~ NM1QC1DOEJOHNN*MIABC123456789~ DTM05020190209~ AMTD8150~ SVCHC>99213150801~ DTM47220190101~ CASCO4570~ AMTB680~ SVCHC>8500310001~ DTM47220190101~ CASCO204100~ SVCHC>3641515001~ DTM47220190101~ CASCO97150~ SE3010060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 75/82 Example 5a: Line Service Tax impacting payment only ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI11.06CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ N1PRHealth Partners of Philadelphia~ N3901 Market St~ N4PhiladelphiaPA19107~ PERCXTE2159914350~ PERBLEDI SupportTE2159914290EM[email protected]~ PERICURwww.healthpart.com~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLPPCN136.2011.06HMCLAIMNUMB111~ NM1QC1LASTFIRSTJ*MI123456789~ NM1821*****XX1447481825~ DTM05020170113~ AMTD836.20~ SVCHC>9921426.23.06~ DTM47220170109~ CASCO4523.2~ REF6RB1~ AMTB63~ SVCHC>36415108~ DTM47220170109~ CASCO452~ REF6RB2~ AMTB68~ SE3110060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 76/82 Example 5b: Line Service Bonuses impacting payment only ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI12.00CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ N1PRHealth Partners of Philadelphia~ N3901 Market St~ N4PhiladelphiaPA19107~ PERCXTE2159914350~ PERBLEDI SupportTE2159914290EM[email protected]~ PERICURwww.healthpart.com~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLPPCN1251210HMCLAIMNUMB111~ NM1QC1LASTFIRSTJ*MI123456789~ NM1821*****XX1447481825~ DTM05020170113~ AMTD825~ SVCHC>992142512~ DTM47220170109~ CASCO455~ CASPR310~ REF6R123~ AMTB620~ SE2710060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 77/82 Example 5c: Line Service Penalty impacting payment only ISA00* 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI8.00CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ N1PRHealth Partners of Philadelphia~ N3901 Market St~ N4PhiladelphiaPA19107~ PERCXTE2159914350~ PERBLEDI SupportTE2159914290EM[email protected]~ PERICURwww.healthpart.com~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLPPCN125810HMCLAIMNUMB111~ NM1QC1LASTFIRSTJ*MI123456789~ NM1821*****XX1447481825~ DTM05020170113~ AMTD825~ SVCHC>99214258~ DTM47220170109~ CASCO455~ CASPR310~ REF6R123~ AMTB620~ SE2710060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 78/82 Example 6: Not Covered/Not Authorized Inpatient Facility claim days ISA00* 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI8000.00CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ N1PRHealth Partners of Philadelphia~ N3901 Market St~ N4PhiladelphiaPA19107~ PERCXTE2159914350~ PERBLEDI SupportTE2159914290EM[email protected]~ PERICURwww.healthpart.com~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLPPATACCT1400008000HMCLAIMNUMBER111~ CASCO19720001~ NM1QC1DOEJOHNN*MIABC123456789~ DTM05020190209~ AMTD838000~ SE2110060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 79/82 Example 8a: Claim submitted with incorrect subscriber as patient and incorrect ID ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P\|~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI120.03CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ N1PRHealth Partners of Philadelphia~ N3901 Market St~ N4PhiladelphiaPA19107~ PERCXTE2159914350~ PERBLEDI SupportTE2159914290EM[email protected]~ PERICURwww.healthpart.com~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLP04777796TLC7771221155120.03HM8838888212111~ NM1QC1MASTERSMARVINL*MI80444444403~ NM1821SHELTON MDBLAKE***XX1666666666~ DTM05020181119~ AMTD8155~ SVCHC\|99393155120.031~ DTM47220181114~ CASCO4534.97~ REFLU11~ REF6R22261822~ AMTB6120.03~ SE2710060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 80/82 Example 8b: Claim submitted with incorrect subscriber name and ID ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P\|~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI35.06CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ N1PRHealth Partners of Philadelphia~ N3901 Market St~ N4PhiladelphiaPA19107~ PERCXTE2159914350~ PERBLEDI SupportTE2159914290EM[email protected]~ PERICURwww.healthpart.com~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLP02333TLC222222111535.0635HM8333333214111~ NM1QC1KEATONALEXP*MI80000006006~ NM1821BLOOD MDRED N***XX1888888886~ DTM05020191119~ AMTD8115~ SVCHC\|9921311535.061~ DTM47220191113~ CASCO4544.94~ CASPR335~ REFLU11~ REF6R22261389~ AMTB670.06~ SE2810060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 81/82 Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation. Example 8c: Claim submitted with for subscriber missing the Middle initial ISA00* 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI2415.25CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ N1PRHealth Partners of Philadelphia~ N3901 Market St~ N4PhiladelphiaPA19107~ PERCXTE2159914350~ PERBLEDI SupportTE2159914290EM[email protected]~ PERICURwww.healthpart.com~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLP05444444TLC999999139032415.25HM8777777782211~ NM1QC1GONZALESSAMMY***MI80455555502~ NM1821GOOD MDROBERT B***XX19999999987~ DTM05020191114~ AMTD83903~ AMTI150~ SVCHC>5940039032415.251~ DTM47220191101~ CASCO451487.75~ REFLU21~ REF6R22215592~ AMTB62415.25~ SE2810060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 82/82	Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
CLP04777796TLC7771221155120.03*HM8838888212111~ NM1QC1MASTERSMARVINL*MI80444444403~ NM1821SHELTON MDBLAKE***XX1666666666~ DTM05020181119~ AMTD8155~ SVCHC\|99393155120.031~ DTM47220181114~ CASCO4534.97~ REFLU11~ REF6R22261822~ AMTB6120.03~ SE2710060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 80/82 Example 8b: Claim submitted with incorrect subscriber name and ID ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P\|~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI35.06CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ N1PRHealth Partners of Philadelphia~ N3901 Market St~ N4PhiladelphiaPA19107~ PERCXTE2159914350~ PERBLEDI SupportTE2159914290EM[email protected]~ PERICURwww.healthpart.com~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLP02333TLC222222111535.0635HM8333333214111~ NM1QC1KEATONALEXP*MI80000006006~ NM1821BLOOD MDRED N***XX1888888886~ DTM05020191119~ AMTD8115~ SVCHC\|9921311535.061~ DTM47220191113~ CASCO4544.94~ CASPR335~ REFLU11~ REF6R22261389~ AMTB670.06~ SE2810060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 81/82 Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation. Example 8c: Claim submitted with for subscriber missing the Middle initial ISA00* 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI2415.25CCHK***********20190816~ TRN1CK NUMBER 11234567890~ REFEVFAC~ N1PRHealth Partners of Philadelphia~ N3901 Market St~ N4PhiladelphiaPA19107~ PERCXTE2159914350~ PERBLEDI SupportTE2159914290EM[email protected]~ PERICURwww.healthpart.com~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLP05444444TLC999999139032415.25HM8777777782211~ NM1QC1GONZALESSAMMY***MI80455555502~ NM1821GOOD MDROBERT B***XX19999999987~ DTM05020191114~ AMTD83903~ AMTI150~ SVCHC>5940039032415.251~ DTM47220191101~ CASCO451487.75~ REFLU21~ REF6R22215592~ AMTB62415.25~ SE2810060875~ GE112345678~ IEA1191511902~ 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 82/82	Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
HIPAA Transaction Standard Companion Guide 835 – Health Care Claim Payment Advice Refers to the Implementation Guides Based on X12 version 005010 Errata Companion Guide Version Number: 1.1 February 2024 Disclaimer Statement The Health Insurance Portability and Accountability Act (HIPAA), sections 160 and 162, require that health care providers, health plans, and health care clearing houses comply with the EDI standards for health care. The HIPAA implementation specifications for ASC X12N standards may be obtained through the Washington Publishing Company on the Internet at http://www.wpcedi.com. The purpose of this companion guide is solely to supplement the HIPAA ASC X12N standards, to provide clarification to the ASC X12N standards, and should not be interpreted as a contract, amendment to a contract or an addendum to a contract. In any instance where this companion guide differs from the HIPAA ASC X12N Implementation Guides, the HIPAA ASC X12N standards shall govern. Substantial effort has been taken to minimize errors; however, SummaCare, Inc, its agents, employees, directors and shareholders shall not be liable or responsible for any errors, omissions or expenses resulting from the use of the information in this document Page of SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 Table of Contents 1 Introduction ................................................................................................................................................4 1.1 Overview 2 Eligibility 3 Data Exchange Frequency 4 Electronic Funds Transfer (EFT) 5 Claim Remittance Processing ...................................................................................................................5 5.1 Interchange Control Structure 5.2 Sorting order of data within the 835 file 5.3 Claims returned within the 835 6 Claims/Batch Matching 7 Bundling/Unbundling 8 Identification Codes and Numbers ............................................................................................................6 8.1 Provider Identifiers 8.2 Subscriber Identifiers 8.3 Payer Claim Control Number 8.4 Adjustment Group and Reason Codes 8.5 Remarks Codes 9 Special Handling .......................................................................................................................................6 9.1 Federal Surprise Act (NSA) 10 Inquiries ...............................................................................................................................................7-10 11 835 Data Element Table 11.1 835 Health Care Claim Payment/Advice – Header 11.2 835 Health Care Claim Payment /Advice – Detail 11.3 835 Health Care Claim Payment/Advice – Summary 12 835 Claim Payment/Advice Transaction Sample ..............................................................................11-12 12.1 Claim Payment Advice Scenario 12.2 Claim Payment /Advice Example ANSI X 12 13 Version History .......................................................................................................................................12 14 Frequently Asked Questions – FAQ .......................................................................................................13 Page of SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 1 Introduction 1.1 Overview This Companion Guide identifies unique information processing or adjudication needs specific to SummaCare, Inc in its implementation of the 835 Health Care Claim Payment Advice and should be used in conjunction with the HIPAA 835 Implementation Guide. Throughout this document, “SummaCare” represents SummaCare, Inc. This companion guide contains three categories of information: • General information applicable to the processing of claims and business edits performed by SummaCare. • The transaction table outlining specific requests for data format or content within the transaction, or describing SummaCare handling of specific data types. • Additional information containing a sample scenario and frequently asked questions (FAQ). All claims (paper and electronic) will be reported on the 835, if a provider/submitter chooses to receive the 835. While SummaCare accepts all ASCX12 compliant transactions, the HIPAA Implementation Guides allow for some discretion in applying the regulations to existing business practices. Understanding SummaCare business practices may expedite claims processing for trading partners as they exchange EDI transactions with SummaCare. 2 Eligibility In order to receive an 835 Health Care Claim Payment Advice, submitters of health care claims can complete the following: • Complete and submit a Trading Partner Agreement to SummaCare or enter into a contractual agreement with a SummaCare contracted Trading Partner. • Complete the SummaCare 835 Registration Form. • Complete testing requirements with SummaCare. 3 Data Exchange Frequency New files may be available each business day by noon eastern standard time. 4 Electronic Funds Transfer (EFT) The SummaCare 835 Transaction is for notification only and does not include Electronic Fund Transfer (EFT) to financial institutions. Providers who would like to Implement EFT can log into their Plan Central account and register or complete the EFT form on SummaCare’s website at http://www.summacare.com/Provider/ResourcesAndSelfServices/EDIRegistration.aspx, complete and mail in the EFT Registration Form to the address on the form. Page of SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 5 Claim Remittance Processing 5.1 Interchange Control Structure 835 transactions are generated one file per Trading Partner during each scheduled payables process. The envelope structure is as follows for each individual check processed within a file. If a Trading Partner receives more than one check payment within the 835 then there will be multiple iterations of the structure below within the file. ISA - Interchange Control Header GS - Functional Group header ST - Transaction Set Header Detail Segments (Please see the Implementation Guide for All possible detail segments) SE - Transaction Set Trailer GE - Functional Group Trailer IEA - Interchange Control Trailer 5.2 Sorting order of data within the 835 file Within the 835 transaction file the Interchange Control Structure(s) are ordered by check number in ascending order. The check number is located in the TRN02 segment. For each check within the 835 transaction the claims are ordered by claim number in ascending order. The claim number is located in the CLP07 segment. 5.3 Claims returned within the 835 Notes that are important to claims processing are as follows: • 835 Transactions are only generated for claims that have a "paid" or "denied" status. Claims still in the adjudication process or returned with an error messages do not receive an 835 response. • If a provider submits claims on paper and EDI claims, SummaCare will generate a format compliant 835 Health Care Claim Payment Advice transaction with required elements. However, the content of the resulting 835 will not be as complete as an 835 resulting from an electronic 837 Claim transaction. • SummaCare will turn off the paper Explanation of Payments (EOP) once a provider starts receiving the 835 transaction. The provider may access Plan Central to review a Portable Document Format (PDF) image of their EOP. To register and access this service please visit http://www.summacare.com/Provider/ ResourcesAndSelfServices.aspx 6 Claims/Batch Matching Please note that there is not batch matching between 837 Health Care Claims and 835 Health Care Claim Payment Advice. 7 Bundling/Unbundling As claims are processed, professional services reflected by procedure codes are bundled or unbundled utilizing SummaCare business processes. Procedure codes are returned for professional health care claims as processed reflecting SummaCare payment record. This does not necessarily reflect procedure codes submitted. Page of SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 8 Identification Codes and Numbers SummaCare uses the standard medical and non-medical code sets indicated in Appendix C of the 835 Payment Advice/Remittance Implementation Guide. 8.1 Provider Identifiers SummaCare accepts the National Provider Identifier and Tax Identification numbers for provider's mandated by the state to obtain one. For exempt providers we will accept the Tax Identification number. 8.2 Subscriber Identifiers The Subscriber Identifier returned on the 835 Claim Payment Advice is the membership identifier that appears within the SummaCare system which could be different than what was submitted on the 837 Health Care Claims transaction. If this identifier differs from that which was submitted, assume the returned identifier on the 835 transactions is correct. 8.3 Payer Claim Control Number The Payer Claim Control Number (Payer Patient Control Number in the 2100 loop, CLP07) is the 12-digit claim number assigned to each claim by SummaCare. Receivers of the 835 Health Care Claim Payment Advice should use their Patient Control Number (Patient Control Number CLP01) and dates of service, in conjunction with the CLP07 value to match claims with remittances. If the Patient Control Number is submitted on paper claims, then this number will be returned on the 835 Health Care Claim Payment Advice. If there is no Patient Control Number on the paper claim, then the value of "0" will be returned. 8.4 Adjustment Group and Reason Codes For claim adjustment reason code use code source 139 and for Health Care Remark Codes, use source code 411. 8.5 Remarks Codes We will be returning the HIPAA Standard Remarks Codes (Loop2110, segment LQ02) along with our current Explanation Codes (Loop 2110, segment REF02). 9 Special Handling In the event that we are unable to produce an 835 Health Care Claim Payment Advice electronically, SummaCare will generate a paper Explanation of Payment (EOP). 9.1 Federal No Surprises Act (NSA) SummaCare complies with both federal and state NSA requirements. When RARC code N862 is found in the LQ segment, please reference additional information regarding federal NSA on SummaCare.com using the following link: https://www.summacare.com/no-surprises-act 10 Inquiries For inquiries concerning the EFT (Electronic Funds Transfer) please contact our Finance Department at (330) 996-8461. All other inquiries should contact: SummaCare Provider Support Services at (330) 996-8400 or 1-800-996-8401 or by email: [email protected]. Page of SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 11 835 Data Element Table 11.1 835 Health Care Claim Payment/Advice – Header The 835 Transaction Set Header contains general information about the claim payment, such as Payee,Amount,Payer,Payment method, and Trace Number. The following table explains the header segments and data elements that require specific information for SummaCare processing. Envelope/Section Label Segment Description Value Options for SummaCare Description/Comments Financial Information BPR01 Transaction Handling Code I, C, D I - Remittance information only C-Payment Accompanies Remittance Advice D- Make payment only Financial Information BPR03 Credit / Debit Flag Code C C - Credit Financial Information BPR04 Payment Method Code ACH, CHK ACH - Automated Clearing House CHK - Check Financial Information BPR05 Payment Format Code CCP CCP - Cash Concentration / Disbursement plus Addenda Financial Information BPR06 DFI ID Number Qualifier 01 01 - ABA Transit Routing Number Including Check Digit (9 digits) Financial Information BPR07 Sender DFI ID Number Sender DFI ID Represents Summa Insurance Company/ Summa Health Network/ SummaCare Bank Number Financial Information BPR09 Sender Bank Account Number Sender Bank Account Number Represents Summa Insurance Company/ Summa Health Network / SummaCare Bank Account Number Financial Information BPR10 Originating Company Identifier Same value as the TRN03 This will be sent when the BPR04 is present Financial Information BPR12 DFI ID Number Qualifier 01 01 - ABA Transit Routing Number Including Check Digit (9 digits) Financial Information BPR13 Receiver DFI ID Number Receiver DFI ID Represents Receiver / Provider's Bank Number Financial Information BPR15 Receiver Bank Account Number Receiver Bank Account Number Represents Receiver / Provider's Bank Account Number Financial Information BPR16 Check Issue or EFT Effective Date Date Represent the Check Issue Date or EFT Effective Date Re-association Trace Number TRN02 Check or EFT Trace Number Check Number, Advice Number Check Number- If the Provider Receives a Paper Check Advice Number - If the Provider Receives an EFT Re-association Trace Number TRN03 Payer Identifier 95202 SummaCare Payer Identification Number Receiver Identification REF01 Reference Identification Qualifier EV EV - Receiver ID Number Receiver Identification REF02 Receiver Identifier Receiver's EDI Sender ID Number Represents the Receiver's EDI Sender ID Number Assigned by SUMMACARE Table 1 - 835 Claim Payment / Advice - Header Transaction Set Header LOOP ID - 1000B Payee Identification Payee Identification N103 Identification Code Qualifier XX or FI XX - Centers for Medicare and Medicaid Services National Provider Identifier(NPI) FI - Federal Tax Identification (This should only be sent for Exempt Providers) Payee Identification N104 Payee Identification Code Provider’s NPI Number or Tax ID number Represents the Provider's NPI number or Federal Tax ID number. Page of SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 11.2 835 Health Care Claim Payment /Advice – Detail The 835 Payment Advice detail level contains the explanations of benefits and charges paid, reduced, or denied related to the adjudicated claims and services. The Claim Payment and Service Patient Information are contained in Loops 2100 and 2110 in the following table. The table also explains the situational segments and data elements that require specific information for SummaCare processing. Table 2 - 835 Claim Payment / Advice - Detail LOOP ID - 2100 Claims Payment Information Envelope/Section Label Segment Description Value Options for SummaCare Description/Comments Claim Payment Information CLP01 Patient Control Number Patient Control Number (UB04) Patient Account Number (HCFA) For Electronic Claims, this field will contain the value received in CLM01 on the inbound 837. For Paper Claims, this field will contain the value received in block 26 on the HCFA and block 3a	HIPAA SummaCare 835 Companion Guide 5010.pdf
Accompanies Remittance Advice D- Make payment only Financial Information BPR03 Credit / Debit Flag Code C C - Credit Financial Information BPR04 Payment Method Code ACH, CHK ACH - Automated Clearing House CHK - Check Financial Information BPR05 Payment Format Code CCP CCP - Cash Concentration / Disbursement plus Addenda Financial Information BPR06 DFI ID Number Qualifier 01 01 - ABA Transit Routing Number Including Check Digit (9 digits) Financial Information BPR07 Sender DFI ID Number Sender DFI ID Represents Summa Insurance Company/ Summa Health Network/ SummaCare Bank Number Financial Information BPR09 Sender Bank Account Number Sender Bank Account Number Represents Summa Insurance Company/ Summa Health Network / SummaCare Bank Account Number Financial Information BPR10 Originating Company Identifier Same value as the TRN03 This will be sent when the BPR04 is present Financial Information BPR12 DFI ID Number Qualifier 01 01 - ABA Transit Routing Number Including Check Digit (9 digits) Financial Information BPR13 Receiver DFI ID Number Receiver DFI ID Represents Receiver / Provider's Bank Number Financial Information BPR15 Receiver Bank Account Number Receiver Bank Account Number Represents Receiver / Provider's Bank Account Number Financial Information BPR16 Check Issue or EFT Effective Date Date Represent the Check Issue Date or EFT Effective Date Re-association Trace Number TRN02 Check or EFT Trace Number Check Number, Advice Number Check Number- If the Provider Receives a Paper Check Advice Number - If the Provider Receives an EFT Re-association Trace Number TRN03 Payer Identifier 95202 SummaCare Payer Identification Number Receiver Identification REF01 Reference Identification Qualifier EV EV - Receiver ID Number Receiver Identification REF02 Receiver Identifier Receiver's EDI Sender ID Number Represents the Receiver's EDI Sender ID Number Assigned by SUMMACARE Table 1 - 835 Claim Payment / Advice - Header Transaction Set Header LOOP ID - 1000B Payee Identification Payee Identification N103 Identification Code Qualifier XX or FI XX - Centers for Medicare and Medicaid Services National Provider Identifier(NPI) FI - Federal Tax Identification (This should only be sent for Exempt Providers) Payee Identification N104 Payee Identification Code Provider’s NPI Number or Tax ID number Represents the Provider's NPI number or Federal Tax ID number. Page of SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 11.2 835 Health Care Claim Payment /Advice – Detail The 835 Payment Advice detail level contains the explanations of benefits and charges paid, reduced, or denied related to the adjudicated claims and services. The Claim Payment and Service Patient Information are contained in Loops 2100 and 2110 in the following table. The table also explains the situational segments and data elements that require specific information for SummaCare processing. Table 2 - 835 Claim Payment / Advice - Detail LOOP ID - 2100 Claims Payment Information Envelope/Section Label Segment Description Value Options for SummaCare Description/Comments Claim Payment Information CLP01 Patient Control Number Patient Control Number (UB04) Patient Account Number (HCFA) For Electronic Claims, this field will contain the value received in CLM01 on the inbound 837. For Paper Claims, this field will contain the value received in block 26 on the HCFA and block 3a on the UB04 claim forms. If the patient control number was not present on the inbound claim, a zero will appear here. Claim Payment Information CLP07 Payer Claim Control Number SUMMACARE Claim Number Represents the claim number assigned by SUMMACARE Patient Name NM108 Identification Code Qualifier MI MI - Member Identification Number Patient Name NM109 Patient Identifier SummaCare member number plus 2 digit suffix Represents the Member Identification Number Insured Name NM108 Identification Code Qualifier MI This segment is only used when the patient is not the subscriber MI - Member Identification Number Insured Name NM109 Patient Identifier SummaCare Subscriber's number This segment is only used when the patient is not the subscriber Represents the Member Identification Number Service Provider Name NM108 Identification Code Qualifier XX or FI XX -Centers for Medicare and Medicaid Services National Provider Identifier(NPI) FI - Federal Tax Identification(This should only be sent for Exempt Providers) Service Provider Name NM109 Identification Code Provider’s NPI Number or Tax ID Number Represents the Provider ID Claim Date DTM01 Date / Time Qualifier One of the following values: 232,233 232- Claim Statement Period Start 233 - Claim statement Period End Claim Date DTM02 Date Date specified by the code used in DTM01 Date specified by the code used in DTM01 LOOP ID - 2110 Service Payment Information Service Payment Information SVC01-1 Product or Service ID Qualifier One of the following values: AD HC NU AD - American Dental Association Codes HC - Health Care Financing Administration Common Procedural Coding System Codes (HCPCS) NU - National Uniform Billing Committee Codes (NUBC) UB92 codes Service Payment Information SVC06-2 Product/Service ID Procedure Code This element will be used if the submitted procedure code was bundled.The new bundled procedure code will be placed here. Service Date DTM01 Date/Time Qualifier One of the following values: 150, 151 or 472 150 - Service Period Start 151 - Service Period End 472 - Service Service Date DTM02 Date Service date Service date Service Identification REF01 Reference Identification Qualifier E9 E9 - Attachment Code Service Identification REF02 Reference Identification EX codes attached to the Service Line without the description of the EX Code. This represents SummaCare’s internal explanation code that is shown on the paper EOP. Page of SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 11.3 835 Health Care Claim Payment/Advice – Summary The summary level contains the Provider Level Adjustment Segment and provides information related to adjustments to the payment amount not specific to the Detail level. The adjustments can either increase or decrease the actual payment. The following table also explains the situational segments and data elements that require specific information for SummaCare Processing. Table 3 - 835 Claim Payment / Advice - Summary Envelope/Section Label Segment Description Value Options for SummaCare Description/Comments Provider Level Adjustment PLB01 Provider Identifier Payee ID Number Represents the Payee NPI. If the Payee is not required under the Mandate to acquire an NPI Number this will represent the ID Number assigned by SUMMACARE. Page of 12 835 Claim Payment/Advice Transaction Sample 12.1 Claim Payment Advice Scenario On September 2, 2023, Jonathan Doe was experiencing pain in his leg and ankle. He was taken to Healthy Hospital for an x-ray of his foot and ankle. The hospital submitted the bill to their clearinghouse. On September 18, 2023, the clearinghouse transmitted a claim to SummaCare in the 837I file format, for $583.70. On September 25, 2023, SummaCare issued a check for $171.55 to Healthy Hospital for their services. Claim Information Payment: $175.11 Check Date: 9/25/2023 Facility Billed Amount: $583.70 Check #: 97CF0000000411 Facility TIN: 207661234 Claim Production run date: 9/18/2023 Payer Name: SummaCare Payer Address: 1200 E. Market Street Suite 400 Akron, OH 44305-4018 Facility: Healthy Hospital Facility National Provider Identification (NPI) Number: 1234567890 Patient: Jonathan Doe Patient ID: 98765432103 Patient Account #: 330866922 Date of Service: 9/2/2023 CPT Codes: 73610, 73630 Revenue Codes: 320 Adjustment: $408.59 due to a contractual obligation Provider System Control #: 230920E03109 SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 Page of 12.2 Claim Payment /Advice Example ANSI X 12 ST8353207~ BPRI175.11CCHK***********20230925~ TRN197CF0000000411207661234~ DTM40520230918~ N1PRSUMMACARE~ N31200 E. MARKET STREET SUITE 400~ N4AKRONOH44305~ N1PEHEALTHY HOSPITALFI123456789~ N3PO BOX 625~ N4BURLINGTONVT05402~ REFPQV299~ LX1~ CLP3308669221583.7175.1113230920E03109131~ NM1QC1DOEJONATHAN***MI98765432103~ NM1IL1DOEJONATHAN***MI987654321~ NM1822HEALTHY HOSPITAL***XX1234567890~ DTM23220230902~ DTM23320230902~ SVCHC:73610297.4089.223201~ DTM47220230902~ CASCO45208.18~ REFE9PA~ AMTB689.22~ SVCHC:73630286.3085.893201~ DTM47220230902~ CASCO45200.41~ REFE9PA~ AMTB685.89~ SE223207~ SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010 13 Version History The following Version History is provided to easily identify updates from the last version of this Companion Guide. Page of Version Date Updated Update 1.0 April 2023 Added: 9.1 Federal No Surprises Act (NSA) SummaCare complies with both federal and state NSA requirements. When RARC code N862 is found in the LQ segment, please reference additional information regarding federal NSA on SummaCare.com using the following link: https://www.summacare.com/no-surprises-act 1.1 February 2024 Update: Examples given on pages 9 and 10 were updated with more current information. 14 Frequently Asked Questions - FAQ 1. What is Electronic Data Interchange? Electronic Data Interchange (EDI) allows providers to submit claims, retrieve remittance advices and retrieve claim file acknowledgements from their computer system to the insurance carrier or clearinghouse. 2. Can I receive my payment and Explanation of Payment Electronically (EOP)? Yes. Providers can receive an Electronic Fund Transfer (EFT) Automated Clearing House (ACH) payment after an EFT Registration form is completed and mailed back to SummaCare. Providers may review their EOP utilizing SummaCare's Provider self service tool of Plan Central. To register or to locate the EFT Registration form please go to http://www.summacare.com/Provider/ResourcesAndSelfServices.aspx. 3. Do you send data on all claims or just paid claims? We send data on all paid, denied and zero dollar charge claims. Data is not returned on electronic claims rejected at time of submission or claims in process in our system. 4. Do you send paper Explanation of Payment along with the electronic version? No, SummaCare will turn off the paper Explanation of Payments (EOP) once a provider starts receiving the 835 transaction. The provider may access Plan Central to review a Portable Document Format (PDF) image of their EOP by going to the following SummaCare website http://www.summacare.com/Provider/ResourcesAndSelfServices.aspx. 5. As a provider can I receive my 835 directly from SummaCare? Yes, SummaCare can set up a direct File Transfer Protocol (FTP) secure internet connection for the provider to directly pick up their 835 from SummaCare. SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010	HIPAA SummaCare 835 Companion Guide 5010.pdf
SummaCare website http://www.summacare.com/Provider/ResourcesAndSelfServices.aspx. 5. As a provider can I receive my 835 directly from SummaCare? Yes, SummaCare can set up a direct File Transfer Protocol (FTP) secure internet connection for the provider to directly pick up their 835 from SummaCare. SUMMACARE COMPANION GUIDE - 835 Health Care Claim Payment Advice - X12 5010	HIPAA SummaCare 835 Companion Guide 5010.pdf
Stedi maintains this guide based on public documentation from Security Health. Contact Security Health for official EDI specifications. To report any errors in this guide, please contact us. X12 835 Health Care Claim Payment/Advice (X221A1) X12 Release 5010 Revised November 20, 2023 Go to Stedi Network 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 View the latest version of this implementation guide as an interactive webpage https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice- x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE POWERED BY Build EDI implementation guides at stedi.com 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 1/124 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 Payer Identification Loop N1 0800 Payer Identification Max use 1 Required N3 1000 Payer Address Max use 1 Required N4 1100 Payer City, State, ZIP Code Max use 1 Required REF 1200 Additional Payer Identification Max use 4 Optional PER 1300 Payer Business Contact Information Max use 1 Optional PER 1300 Payer Technical Contact Information Max use 1 Required PER 1300 Payer WEB Site Max use 1 Optional Payee Identification Loop N1 0800 Payee Identification Max use 1 Required N3 1000 Payee Address Max use 1 Optional N4 1100 Payee City, State, ZIP Code Max use 1 Optional REF 1200 Payee Additional Identification Max use 1 Optional RDM 1400 Remittance Delivery Method Max use 1 Optional 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 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 2/124 Claim Payment Information Loop CLP 0100 Claim Payment Information Max use 1 Required CAS 0200 Claim Adjustment Max use 99 Optional NM1 0300 Corrected Patient/Insured Name Max use 1 Optional NM1 0300 Corrected Priority Payer Name Max use 1 Optional NM1 0300 Crossover Carrier Name Max use 1 Optional NM1 0300 Insured Name Max use 1 Optional NM1 0300 Other Subscriber Name Max use 1 Optional NM1 0300 Patient Name Max use 1 Required NM1 0300 Service Provider Name Max use 1 Optional MIA 0330 Inpatient Adjudication Information Max use 1 Optional MOA 0350 Outpatient Adjudication Information Max use 1 Optional REF 0400 Other Claim Related Identification Max use 5 Optional REF 0400 Rendering Provider Identification Max use 10 Optional DTM 0500 Claim Received Date Max use 1 Optional DTM 0500 Coverage Expiration Date Max use 1 Optional DTM 0500 Statement From or To Date Max use 2 Optional PER 0600 Claim Contact Information Max use 2 Optional AMT 0620 Claim Supplemental Information Max use 13 Optional QTY 0640 Claim Supplemental Information Quantity Max use 14 Optional Service Payment Information Loop SVC 0700 Service Payment Information Max use 1 Required DTM 0800 Service Date Max use 2 Optional CAS 0900 Service Adjustment Max use 99 Optional REF 1000 HealthCare Policy Identification Max use 5 Optional REF 1000 Line Item Control Number Max use 1 Optional REF 1000 Rendering Provider Information Max use 10 Optional REF 1000 Service Identification Max use 8 Optional AMT 1100 Service Supplemental Amount Max use 9 Optional QTY 1200 Service Supplemental Quantity Max use 6 Optional LQ 1300 Health Care Remark Codes Max use 99 Optional 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 3/124 Summary PLB 0100 Provider Adjustment Max use 1 Optional SE 0200 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 4/124 ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange- related control segments Example ISA00 00 XXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXX2501300724^0050100000000 0XX>~ Max use 1 Required ISA-01 I01 Authorization Information Qualifier Identifier (ID) 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 Min 10 Max 10 String (AN) Required 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 Identifier (ID) 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 Min 10 Max 10 String (AN) Required 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 Min 2 Max 2 Identifier (ID) Required 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 Min 15 Max 15 String (AN) Required 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 Min 2 Max 2 Identifier (ID) Required 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 5/124 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 Min 15 Max 15 String (AN) Required 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 YYMMDD format Date (DT) Required Date of the interchange ISA-10 I09 Interchange Time HHMM format Time (TM) Required Time of the interchange ISA-11 I65 Repetition Separator Min 1 Max 1 String (AN) Required 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 Identifier (ID) 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 Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender ISA-14 I13 Acknowledgment Requested Min 1 Max 1 Identifier (ID) Required 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 Min 1 Max 1 Identifier (ID) Required Code indicating whether data enclosed by this interchange envelope is test, production or information I Information 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 6/124 P Production Data T Test Data ISA-16 I15 Component Element Separator Min 1 Max 1 String (AN) Required 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 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 7/124 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GSHPXXXXXXXXXXX2025013017430000X005010X22 1A1~ Max use 1 Required GS-01 479 Functional Identifier Code Identifier (ID) Required Code identifying a group of application related transaction sets HP Health Care Claim Payment/Advice (835) GS-02 142 Application Sender's Code Min 2 Max 15 String (AN) Required Code identifying party sending transmission; codes agreed to by trading partners GS-03 124 Application Receiver's Code Min 2 Max 15 String (AN) Required Code identifying party receiving transmission; codes agreed to by trading partners GS-04 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year GS-05 337 Time HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time (TM) Required 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 Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required 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 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 8/124 GS-08 480 Version / Release / Industry Identifier Code String (AN) 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 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 9/124 Heading ST 0100 Heading > ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST8350001~ Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) 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 Min 4 Max 9 Numeric (N) Required 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. 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 10/124 BPR 0200 Heading > BPR Financial Information To indicate the beginning of a Payment Order/Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and/or information from payer to payee to occur 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 BPRH000000000000000DCHKCCP01XXXXXXXXD AX1391572880XXXXXXXXX01XXXXXDAXXX2025013 0~	Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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 Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required 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 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 8/124 GS-08 480 Version / Release / Industry Identifier Code String (AN) 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 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 9/124 Heading ST 0100 Heading > ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST8350001~ Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) 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 Min 4 Max 9 Numeric (N) Required 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. 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 10/124 BPR 0200 Heading > BPR Financial Information To indicate the beginning of a Payment Order/Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and/or information from payer to payee to occur 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 BPRH000000000000000DCHKCCP01XXXXXXXXD AX1391572880XXXXXXXXX01XXXXXDAXXX2025013 0~ 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 Max use 1 Required BPR-01 305 Transaction Handling Code Identifier (ID) Required Code designating the action to be taken by all parties 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. BPR-02 782 Total Actual Provider Payment Amount Min 1 Max 15 Decimal number (R) Required 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 Identifier (ID) Required Code indicating whether amount is a credit or debit 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 11/124 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 Identifier (ID) 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. CHK Check Use this code to indicate that a check has been issued for payment. BPR-05 812 Payment Format Code Identifier (ID) 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. BPR-06 506 Depository Financial Institution (DFI) Identification Number Qualifier Optional Identifier (ID) 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. BPR-07 507 Sender DFI Identifier Min 3 Max 12 String (AN) Optional Depository Financial Institution (DFI) identification number Usage notes 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 12/124 Use this number for the identifying number of the financial institution sending the transaction into the applicable network. SHP’s Number BPR-08 569 Account Number Qualifier Identifier (ID) 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 Min 1 Max 35 String (AN) Optional 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. SHP’s Account Number BPR-10 509 Payer Identifier String (AN) Optional 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. 1391572880 BPR-11 510 Originating Company Supplemental Code Min 9 Max 9 String (AN) Optional 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 Identifier (ID) 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. 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 13/124 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. BPR-13 507 Receiver or Provider Bank ID Number Min 3 Max 12 String (AN) Optional 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. Routing Number of Receiver or Provider Bank BPR-14 569 Account Number Qualifier Identifier (ID) 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 BPR-15 508 Receiver or Provider Account Number Min 1 Max 35 String (AN) Optional 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. Provider Account Number BPR-16 373 Check Issue or EFT Effective Date CCYYMMDD format Date (DT) Required 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. 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 14/124 TRN 0400 Heading > TRN Reassociation Trace Number 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 TRN1XXXX1391572880XX~ Max use 1 Required TRN-01 481 Trace Type Code Identifier (ID) Required Code identifying which transaction is being referenced 1 Current Transaction Trace Numbers TRN-02 127 Check or EFT Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 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. Remittance Advice Number TRN-03 509 Payer Identifier String (AN) Required 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). 1391572880 TRN-04 127 Originating Company Supplemental Code Min 1 Max 50 String (AN)	Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
Min 3 Max 12 String (AN) Optional 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. Routing Number of Receiver or Provider Bank BPR-14 569 Account Number Qualifier Identifier (ID) 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 BPR-15 508 Receiver or Provider Account Number Min 1 Max 35 String (AN) Optional 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. Provider Account Number BPR-16 373 Check Issue or EFT Effective Date CCYYMMDD format Date (DT) Required 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. 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 14/124 TRN 0400 Heading > TRN Reassociation Trace Number 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 TRN1XXXX1391572880XX~ Max use 1 Required TRN-01 481 Trace Type Code Identifier (ID) Required Code identifying which transaction is being referenced 1 Current Transaction Trace Numbers TRN-02 127 Check or EFT Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 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. Remittance Advice Number TRN-03 509 Payer Identifier String (AN) Required 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). 1391572880 TRN-04 127 Originating Company Supplemental Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 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. 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 15/124 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 16/124 CUR 0500 Heading > CUR Foreign Currency Information 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 CURPRXXX~ Max use 1 Optional CUR-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer CUR-02 100 Currency Code Min 3 Max 3 Identifier (ID) Required Code (Standard ISO) for country in whose currency the charges are specified Usage notes This is the currency code for the payment currency. 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 17/124 REF 0600 Heading > REF Receiver Identification 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 REFEVXX~ Variants (all may be used) REF Version Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EV Receiver Identification Number REF-02 127 Receiver Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 18/124 REF 0600 Heading > REF Version Identification 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 REFF2XXX~ Variants (all may be used) REF Receiver Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F2 Version Code - Local REF-02 127 Version Identification Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 19/124 DTM 0700 Heading > DTM Production Date 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 DTM40520250130~ Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 405 Production DTM-02 373 Production Date CCYYMMDD format Date (DT) Required 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. 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 20/124 1000A Payer Identification Loop Max 1 Required Variants (all may be used) Payee Identification Loop N1 0800 Heading > Payer Identification Loop > N1 Payer Identification 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 N1PRSECURITY HEALTH PLANXVXXXXX~ If either Identification Code Qualifier (N1-03) or Payer Identifier (N1-04) is present, then the other is required Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer N1-02 93 Payer Name String (AN) Required Free-form name ADVOCARE FAMILY HEALTH CENTER MEDICAID SECURITY HEALTH PLAN TPA N1-03 66 Identification Code Qualifier Identifier (ID) 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 Min 2 Max 80 String (AN) Optional 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. 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 21/124 N3 1000 Heading > Payer Identification Loop > N3 Payer Address To specify the location of the named party Example N3XXXXXX~ Max use 1 Required N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 22/124 N4 1100 Heading > Payer Identification Loop > N4 Payer City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXX~ 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 Max use 1 Required N4-01 19 Payer City Name Min 2 Max 30 String (AN) Required 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 Min 2 Max 2 Identifier (ID) Optional 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 Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 23/124 REF 1200 Heading > Payer Identification Loop > REF Additional Payer Identification 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 REFHIXXXXXX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) 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 Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification	Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 22/124 N4 1100 Heading > Payer Identification Loop > N4 Payer City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXX~ 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 Max use 1 Required N4-01 19 Payer City Name Min 2 Max 30 String (AN) Required 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 Min 2 Max 2 Identifier (ID) Optional 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 Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 23/124 REF 1200 Heading > Payer Identification Loop > REF Additional Payer Identification 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 REFHIXXXXXX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) 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 Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 24/124 PER 1300 Heading > Payer Identification Loop > PER Payer Business Contact Information 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 PERCXPROVIDER RELATIONSTE8005481224FXXEXX X~ Variants (all may be used) PER Payer Technical Contact Information PER Payer WEB Site 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 Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Payer Contact Name String (AN) Optional 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). PROVIDER RELATIONS PER-03 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number TE Telephone 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 25/124 PER-04 364 Payer Contact Communication Number String (AN) Optional Complete communications number including country or area code when applicable 8005481224 PER-05 365 Communication Number Qualifier Identifier (ID) 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 Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 26/124 PER 1300 Heading > Payer Identification Loop > PER Payer Technical Contact Information 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 PERBLXXXXXXEMXXXXXURXXEXXXX~ Variants (all may be used) PER Payer Business Contact Information PER Payer WEB Site 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 Max use >1 Required PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named BL Technical Department PER-02 93 Payer Technical Contact Name Min 1 Max 60 String (AN) Optional 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 Identifier (ID) 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 Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 27/124 PER-05 365 Communication Number Qualifier Identifier (ID) 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 Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number 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 Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 28/124 1000A Payer Identification Loop end PER 1300 Heading > Payer Identification Loop > PER Payer WEB Site 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 PERICURXX~ Variants (all may be used) PER Payer Business Contact Information PER Payer Technical Contact Information Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number UR Uniform Resource Locator (URL) PER-04 364 Communication Number Min 1 Max 256 String (AN) Required 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. 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 29/124 1000B Payee Identification Loop Max 1 Required Variants (all may be used) Payer Identification Loop N1 0800 Heading > Payee Identification Loop > N1 Payee Identification 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 N1PEXXXFIXX~ Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PE Payee N1-02 93 Payee Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) 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. 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 Min 2 Max 80 String (AN) Required 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. 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 30/124 N3 1000 Heading > Payee Identification Loop > N3 Payee Address 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 N3XXXXXXXXX~ Max use 1 Optional N3-01 166 Payee Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payee Address Line Min 1 Max 55 String (AN) Optional Address information 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 31/124 N4 1100 Heading > Payee Identification Loop > N4 Payee City, State, ZIP Code 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 N4XXXXXXXXXXXXXXXX~ Only one of Payee State Code (N4-02) or Country Subdivision Code	Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf

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