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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 (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 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 32/124 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 REFPQXXX~ Max use >1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 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 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 33/124 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 RDMBMXXXXXXXX~ 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 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 34/124 1000B Payee Identification Loop end Heading end Contains URL web address or e-mail address. 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 35/124 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, 8:52 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 36/124 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 TS3XXX20250130000000000000*****000000000 00000000*0000000000000000000000*000000000 0000000000000000000000*000~ 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 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 37/124 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 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 38/124 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	Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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 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 37/124 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 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 38/124 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 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 39/124 See TR3 note 3. 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 40/124 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 TS200000000000000000000000000000000000000000 000000000000000000000000000000000000000000000 0000000000000000000000000000000000000000000 0000000000000000000000000000000000000000000~ 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 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 41/124 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 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 42/124 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 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 43/124 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 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 44/124 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 CLPXXXX20000000000000000000000000MBXXX XXX*XXXX000000000000*000~ 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 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 45/124 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	Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
see section 1.3.2, Other Usage Limitations. Example CLPXXXX20000000000000000000000000MBXXX XXXXXXX000000000000000~ 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 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 45/124 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 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 46/124 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 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 47/124 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 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 48/124 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 CASPRX0000000000000000000000XXX00000000000 000000X0000000000000000000000000XXX00000000 000XXX00000000000000XXXX0000000000000000000 0~ 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 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 49/124 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	Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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 CASPRX0000000000000000000000XXX00000000000 000000X0000000000000000000000000XXX00000000 000XXX00000000000000XXXX0000000000000000000 0~ 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 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 49/124 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 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 50/124 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 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 51/124 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 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 52/124 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 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 53/124 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 NM1742XXXXXXX*XXXXXXCXX~ 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 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 54/124 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 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 55/124 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 NM1PR2XXXXX****PPXXX~ 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 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 56/124 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 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 57/124 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 NM1TT2XXXXX***PPXXX~ 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	Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
> 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 NM1PR2XXXXX***PPXXX~ 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 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 56/124 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 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 57/124 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 NM1TT2XXXXX***PPXXX~ 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 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 58/124 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 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 59/124 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 NM1IL1XXXXXXXXXXXXXXXXMIXX~ 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 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 60/124 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) 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 Usage notes Security Health Plan Member ID 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 61/124 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 NM1GB2XXXXXXXXXXXX*XXXXXXIIXXX~ 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 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 62/124 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 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 63/124 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*XXXXMIXXXXXX~ 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 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 64/124 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 Usage notes Security Health Plan Member ID 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 65/124 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 NM1821XXXXXXXXXXXXX*XXXXX*XXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name	Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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 NM1QC1XXXXXXXXXXXXXXXXMIXXXXXX~ 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 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 64/124 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 Usage notes Security Health Plan Member ID 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 65/124 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 NM1821XXXXXXXXXXXXX*XXXXXXXXX~ 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 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 66/124 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 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 67/124 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 MIA00000000000000000000000000000000000XX000 0000000000000000000000000000000000000000000 00000000000000000000000000000000000000000000 0000000000000XXXXXXXXXXXXXXXX000000000000~ 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 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 68/124 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 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 69/124 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 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 70/124 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 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 71/124 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 MOA0000000000XXXXXXXXXXXXXXXX0000000000~ 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	Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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 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 70/124 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 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 71/124 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 MOA0000000000XXXXXXXXXXXXXXXX0000000000~ 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 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 72/124 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 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 73/124 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 REFIGX~ 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 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. 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 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes For ‘IL’, Security Health Plan’s carrier identifier For ‘1W’, Member SSN For ‘F8’, Security Health Plan’s Original Claim Identifier For ‘IG’, Security Health Plan’s policy identifier 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 74/124 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 REFLUXXXXX~ 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 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 75/124 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 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 76/124 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 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 77/124 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 DTM232*20250130~ 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 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 78/124 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	Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
patient's coverage. 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 77/124 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 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 78/124 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 PERCXXXXFXXXXFXXXXEXXXXXX~ 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 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 79/124 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 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 80/124 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 AMTI000000000000000~ 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). I Interest See section 1.10.2.9 for additional information. 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 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 81/124 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 QTYLE00000~ 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 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 82/124 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 SVCHC>XXXX>XX>XX>XX>XX000000XXXXX00000000000 0NU>XXXX>XX>XX>XX>XX>XXX00~ 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 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 83/124 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	Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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 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 83/124 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 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 84/124 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 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 85/124 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 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 86/124 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 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 87/124 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 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 88/124 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 CASPIXXX0000000000000XXX0000000000XXX000 000000000000000000000XX00000000000000000XX0 000000000000000000XX0000*0~ 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	Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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 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 88/124 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 CASPIXXX0000000000000XXX0000000000XXX000 000000000000000000000XX00000000000000000XX0 000000000000000000XX00000~ 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 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 89/124 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 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 90/124 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 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 91/124 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 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 92/124 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 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 93/124 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 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 94/124 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 REF6R*X~ 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 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 95/124 REF 1000 Detail > Header Number Loop >	Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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 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 94/124 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 REF6RX~ 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 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 95/124 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 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 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 96/124 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 REFBBXXX~ 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 BB Authorization Number 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 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 97/124 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 AMTB60~ 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. 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 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 98/124 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 QTYZK000~ 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 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 99/124 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 LQRXX~ 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 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 100/124 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 PLBXXXX20250130HM>XXX000000000000XX>XXXXX00 000000000XX>XXXX00XX>XXXXXX000000000XX>XXXX X00000XX>XXXXXX0000~ 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 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 101/124 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	Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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 PLBXXXX20250130HM>XXX000000000000XX>XXXXX00 000000000XX>XXXX00XX>XXXXXX000000000XX>XXXX X00000XX>XXXXXX0000~ 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 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 101/124 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 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 102/124 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 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 103/124 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 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 104/124 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 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 105/124 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	Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
- Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 104/124 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 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 105/124 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 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 106/124 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 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 107/124 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 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 108/124 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE0000000000000~ 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 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 109/124 IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA00000000000000~ 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 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 110/124 EDI Samples Example 1: Dollars and Data Sent Separately ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST835112233~ BPRI1100CACHCCP01888999777DA246810121391572880*01111333555DA14444420190316~ TRN1717006665551391572880~ DTM40520190314~ N1PRADVOCARE~ 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 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 111/124 Example 2: Multiple Claims Single Check ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83535681~ BPRI810.8CCHK***********20190331~ TRN1123451391572880~ REFEVXYZ CLEARINGHOUSE~ N1PRADVOCARE~ 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 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 112/124 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 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 113/124 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 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 114/124 DTM47220190324~ CASCO4517~ AMTB637~ SVCAD>D12082920~ DTM47220190324~ CASCO459~ AMTB620~ SE18335681~ GE112345678~ IEA1191511902~ 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 115/124 Example 3: Claim Specific Negotiated Discount ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83535681~ BPRI132CCHK***********20190331~ TRN1123451391572880~ REFEVCLEARINGHOUSE~ N1PRADVOCARE~ 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 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 116/124 Example 4: Claim Adjustment Reason Code 45 ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI80.00CCHK***********20190816~ TRN1CK NUMBER 11391572880~ REFEVFAC~ DTM40520190827~ N1PRADVOCARE~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8005481224~ 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 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 117/124 Example 5a: Line Service Tax impacting payment only ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI11.06CCHK***********20190816~ TRN1CK NUMBER 11391572880~ REFEVFAC~ DTM40520190827~ N1PRADVOCARE~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8005481224~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLPPCN136.2011.0612CLAIMNUMB111~ NM1QC1LASTFIRSTJ*MI123456789~ NM1821*****XX1447481825~ MOA**N25~ REF1L102345~ DTM05020170113~ AMTAU36.20~ SVCHC>9921426.23.06~ DTM47220170109~ CASCO4523.2137-.06~ REF6RB1~ AMTB63~ SVCHC>36415108~ DTM47220170109~ CASCO452~ REF6RB2~ AMTB68~ SE3410060875~ GE112345678~ IEA1191511902~ 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 118/124 Example 5b: Line Service Bonuses impacting payment only ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI12.00CCHK***********20190816~ TRN1CK NUMBER 11391572880~ REFEVFAC~ DTM40520190827~ N1PRADVOCARE~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8005481224~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLPPCN125121012CLAIMNUMB111~ NM1QC1LASTFIRSTJ*MI123456789~ NM1821*****XX1447481825~ MOA**N25~ REF1L102345~ DTM05020170113~ AMTAU25~ SVCHC>992142512~ DTM47220170109~ CASCO455161-2~ CASPR310~ REF6R123~ AMTB620~ SE3010060875~ GE112345678~ IEA1191511902~ 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 119/124 Example 5c: Line Service Penalty impacting payment only ISA00* 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI8.00CCHK***********20190816~ TRN1CK NUMBER 11391572880~ REFEVFAC~ DTM40520190827~ N1PRADVOCARE~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8005481224~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLPPCN12581012CLAIMNUMB111~ NM1QC1LASTFIRSTJ*MI123456789~ NM1821*****XX1447481825~ MOA**N25~ REF1L102345~ DTM05020170113~ AMTAU25~ SVCHC>99214258~ DTM47220170109~ CASCO455B42~ CASPR310~ REF6R123~ AMTB620~ SE3010060875~ GE112345678~ IEA1191511902~ 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 120/124 Example 6: Not Covered/Not Authorized Inpatient Facility claim days ISA00* 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI8000.00CCHK***********20190816~ TRN1CK NUMBER 11391572880~ REFEVFAC~ DTM40520190827~ N1PRADVOCARE~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8005481224~ 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 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 121/124 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 11391572880~ REFEVFAC~ DTM40520190827~ N1PRADVOCARE~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8005481224~ 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~ DTM23220191114~ DTM23320181114~ DTM05020181119~ AMTAU155~ SVCHC\|99393155120.031~ DTM47220181114~ CASCO4534.97~ REF6R22261822~ AMTB6120.03~ SE3210060875~ GE112345678~ IEA1191511902~ 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 122/124 Example 8b: Claim submitted with incorrect subscriber name and ID ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P\|~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI35.06CCHK***********20190816~ TRN1CK NUMBER 11391572880~ REFEVFAC~ DTM40520190827~ N1PRADVOCARE~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8005481224~ 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~ DTM23220191113~ DTM23320191113~ DTM05020191119~ AMTAU115~ SVCHC\|9921311535.061~ DTM47220191113~ CASCO4544.94~ CASPR335~ REF6R22261389~ AMTB670.06~ SE3310060875~ GE112345678~ IEA1*191511902~ 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 123/124	Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI80.00CCHK***********20190816~ TRN1CK NUMBER 11391572880~ REFEVFAC~ DTM40520190827~ N1PRADVOCARE~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8005481224~ 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 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 117/124 Example 5a: Line Service Tax impacting payment only ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI11.06CCHK***********20190816~ TRN1CK NUMBER 11391572880~ REFEVFAC~ DTM40520190827~ N1PRADVOCARE~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8005481224~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLPPCN136.2011.0612CLAIMNUMB111~ NM1QC1LASTFIRSTJ*MI123456789~ NM1821*****XX1447481825~ MOA**N25~ REF1L102345~ DTM05020170113~ AMTAU36.20~ SVCHC>9921426.23.06~ DTM47220170109~ CASCO4523.2137-.06~ REF6RB1~ AMTB63~ SVCHC>36415108~ DTM47220170109~ CASCO452~ REF6RB2~ AMTB68~ SE3410060875~ GE112345678~ IEA1191511902~ 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 118/124 Example 5b: Line Service Bonuses impacting payment only ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI12.00CCHK***********20190816~ TRN1CK NUMBER 11391572880~ REFEVFAC~ DTM40520190827~ N1PRADVOCARE~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8005481224~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLPPCN125121012CLAIMNUMB111~ NM1QC1LASTFIRSTJ*MI123456789~ NM1821*****XX1447481825~ MOA**N25~ REF1L102345~ DTM05020170113~ AMTAU25~ SVCHC>992142512~ DTM47220170109~ CASCO455161-2~ CASPR310~ REF6R123~ AMTB620~ SE3010060875~ GE112345678~ IEA1191511902~ 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 119/124 Example 5c: Line Service Penalty impacting payment only ISA00* 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI8.00CCHK***********20190816~ TRN1CK NUMBER 11391572880~ REFEVFAC~ DTM40520190827~ N1PRADVOCARE~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8005481224~ PERBLEDITE8002223333EM[email protected]~ PERICURWWW.ANYPAYER.COM~ N1PEPROVIDERXX1123454567~ N32255 ANY ROAD~ N4ANY CITYCA12211~ REFTJ123456789~ LX1~ CLPPCN12581012CLAIMNUMB111~ NM1QC1LASTFIRSTJ*MI123456789~ NM1821*****XX1447481825~ MOA**N25~ REF1L102345~ DTM05020170113~ AMTAU25~ SVCHC>99214258~ DTM47220170109~ CASCO455B42~ CASPR310~ REF6R123~ AMTB620~ SE3010060875~ GE112345678~ IEA1191511902~ 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 120/124 Example 6: Not Covered/Not Authorized Inpatient Facility claim days ISA00* 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P>~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI8000.00CCHK***********20190816~ TRN1CK NUMBER 11391572880~ REFEVFAC~ DTM40520190827~ N1PRADVOCARE~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8005481224~ 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 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 121/124 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 11391572880~ REFEVFAC~ DTM40520190827~ N1PRADVOCARE~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8005481224~ 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~ DTM23220191114~ DTM23320181114~ DTM05020181119~ AMTAU155~ SVCHC\|99393155120.031~ DTM47220181114~ CASCO4534.97~ REF6R22261822~ AMTB6120.03~ SE3210060875~ GE112345678~ IEA1191511902~ 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 122/124 Example 8b: Claim submitted with incorrect subscriber name and ID ISA00 00 ZZABCPAYER ZZABCPAYER 1908270212^005011915119020P\|~ GSHPABCDABCD201908271234567812345678X005010X221A1~ ST83510060875~ BPRI35.06CCHK***********20190816~ TRN1CK NUMBER 11391572880~ REFEVFAC~ DTM40520190827~ N1PRADVOCARE~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8005481224~ 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~ DTM23220191113~ DTM23320191113~ DTM05020191119~ AMTAU115~ SVCHC\|9921311535.061~ DTM47220191113~ CASCO4544.94~ CASPR335~ REF6R22261389~ AMTB670.06~ SE3310060875~ GE112345678~ IEA1191511902~ 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 123/124 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 11391572880~ REFEVFAC~ DTM40520190827~ N1PRADVOCARE~ N31 WALK THIS WAY~ N4ANYCITYOH45209~ PERCXTE8005481224~ 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~ DTM23220191101~ DTM23320191101~ DTM05020191114~ AMTAU3903~ SVCHC>5940039032415.251~ DTM47220191101~ CASCO451487.75~ REF6R22215592~ AMTB62415.25~ SE3210060875~ GE112345678~ IEA1191511902~ 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 124/124	Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
837 Health Care Claim Companion Guide Professional and Institutional Revised December 2011 Table of Contents Introduction ........................................................................................................... 3 Purpose ................................................................................................................ 3 References ........................................................................................................... 3 Additional information ........................................................................................... 4 Delimiters Supported ......................................................................................... 4 Maximum Limitations ......................................................................................... 4 Submission Specifications ................................................................................. 4 Interchange Control Header Specification ............................................................ 6 Interchange Control Trailer Specification .............................................................. 6 Functional Group Header Specification ................................................................ 7 Functional Group Trailer Specification .................................................................. 7 837 Professional Claim Transaction Specifications .............................................. 8 837 Institutional Claim Transaction Specifications .............................................. 10 2 Introduction The Health Insurance Portability and Accountability Act (HIPAA) of 1996 was passed in order to provide better access to health insurance, limit fraud and abuse, and reduce administrative costs of the health care industry. This act required the Department of Health and Human Services (HHS) to adopt standards that support the electronic data interchange (EDI) of health care transactions. In order for the industry to achieve its desired goal, all organizations involved in electronic interchange of data must comply with the standard transactions and code sets that have been developed. These guidelines are outlined in the ANSI X12N 837 Health Care Claims transaction implementation guides. By adopting these standards the efficiency and effectiveness of the health care will improve by encouraging the use of electronic data interchange throughout the industry. This latest version of the Companion Guide contains the changes necessary to ensure compliance with 45 CFR Part 162, CMS-009-F. Purpose The purpose of this document is to provide submitters with the necessary information to successfully submit electronic claims to Advanced Behavioral Health, Inc (ABH). This companion guide should be used in combination with the ANSI X12N 837 implementation guides. These guides are available from Washington Publishing Company on their website at www.wpc- edi.com/hipaa/. Types of transactions accepted by ABH are: • 837 Professional Health Care Claim – ASC X12 837 • 837 Institutional Health Care Claim – ASC X12 837 For those submitters who have previously submitted State of CT General Assistance batch claims electronically, no changes have been made other than the names of the parties involved. For those submitters who have not submitted electronic claims in the past, this companion guide will describe specific requirements necessary for processing claims through Advanced Behavioral Health’s system. This guide in no way replaces any requirements that are found in the ANSI X12N implementation guides. References Listed below are some additional websites containing information that may be helpful during the implementation process: Accredited Standards Committee (ASC X12N) – http://www.x12n.org/ Centers for Medicare and Medicaid Services (CMS) – http://www.cms.hhs.gov/hipaa/ United States Department of Health and Human Services (DHHS) – http://aspe.hhs.gov/admnsimp/ Washington Publishing Company – http://wpc-edi.com/hipaa/ 3 Additional information Delimiters Supported A delimiter is a character that is used to separate data elements, or mark the end of a segment. The preferred delimiters for electronic data are an (*) asterisk for separation of data elements, a (:) colon for separation of sub-elements, and (~) tilde for indication of a segment end. Other delimiters will be accepted according to the ANSI X12N guidelines. Note that once a delimiter has been specified, it cannot be used in the data elements transferred or it will cause the file to be rejected. Maximum Limitations The 837 transaction is designed to submit one or more claims per billing provider. The hierarchy built into the structure is billing provider, subscriber, patient, claim, and claim service. The number of times that each of these loops may repeat is defined in the implementation guides. For example, there cannot be more than 100 claims per client, and no more than 50 service lines per professional claim/999 service lines per institutional claim. ABH will require that only one interchange be submitted per transaction. In addition, there may be only one type of claim (institutional or professional) submitted per interchange, and therefore per file. When files are validated, after being submitted to ABH, they will be checked and accepted (pass) or rejected (fail) based on the entire file’s formatting. Therefore, partial files will not be accepted. Providers will be notified of this response via a download page on the ABH website. If a file is rejected, the message will indicate to the provider what they will need to correct. If there are questions about any error messages that are unclear, please contact the ABH customer service for assistance. Submission Specifications Provider organizations who wish to submit electronic 837 transactions to Advanced Behavioral Health must have a valid submitter id and password. If you do not have this information you may acquire one by contacting the Customer Support at 800-606-3677 X6440 or downloading, completing and submitting the form on ABH’s website at http://www.abhct.com/resources_gabhp.asp. In addition, provider organizations wishing to submit batch claims electronically to ABH must submit one accepted, error free test file and receive verification that the file loaded successfully before submitting production files. In order to submit test files, an ID and password will be assigned by filling out the access form referenced above. The ID will allow submitters to submit only test files until the successful file has been received, at which time the ID will be activated for production files. Provider organizations who will be submitting their claims through the single data-entry claims system on the Internet will not need to test any files and will be able to start submitting claims as soon as they receive their ID and password. 4 If your provider organization utilizes a third-party health care clearinghouse or other agency to submit batch claim files, the organization must submit a copy of a signed Business Associate or Trading Partner agreement along with the access request form. The Department of Mental Health & Addiction Services reserves the right to make final decisions regarding approval of access for third-party agencies. If you have further questions about obtaining access for a third- party agency, please contact our Provider Relations Department at (800) 606-3677, Ext. 6440. 5 Interchange Control Header/Trailer Specifications Seg Data Element Name Usage Comments Expected Value ISA Interchange Control Header R ISA01 Authorization Information Qualifier R Use '03' Additional Data Identification to indicate that a login ID is present in ISA02. ISA02 Authorization Information R Information used for additional identification or authorization. Use the ABH Submitter ID as the login ID. ISA03 Security Information Qualifier R Use '01 Password to indicate that a password is present in ISA04. ISA04 Security Information R Additional security information identifying the sender. Use the ABH Submitter ID password. ISA05 Interchange ID Qualifier R Refer to the implementation guide for a list of valid qualifiers. ISA06 Interchange Sender ID R Refer to the implementation guide specifications. ISA07 Interchange ID Qualifier R Use 'ZZ' Mutually Defined ISA08 Interchange Receiver ID R Use 'ABH ' ISA09 Interchange Date R Date format YYMMDD ISA10 Interchange Time R Time format HHMM ISA11 Interchange Repitition Separator R ISA12 Interchange Control Version Number R Valid values: '00501' Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003 Use the current standard approved for the ISA/IEA envelope. ISA13 Interchange Control Number R The interchange control number must match the interchange trailer IEA02. This value is to be defined by the senders system. If not used, this field must be zero filled. ISA14 Acknowledgement Requested R Valid values: '0' No Acknowledgement Requested '1' Interchange Acknowledgement Requested ISA15 Usage Indicator R Valid values: 'P' Production 'T' Test This Usage Indicator should be set appropriately. When submitting initial tests use 'T', for all other files use 'P'. ISA16 Component Element Separator R The delimiter must be a unique character not found in any of the data included in the batch. This element will contain the delimiter that will be used to separate components within a data element. This value must be different from the element separator and segment terminator. Seg Data Element Name Usage Comments Expected Value IEA Interchange Control Trailer R IEA01 Number of Included Functional Groups R Count of the number of functional groups in the interchange. IEA02 Interchange Control Number R The interchange control number in IEA02 must match the interchange header value sent in ISA13. The interchange control numbers in the IEA and ISA segments will be compared. If the numbers do not match the file will be rejected. Header Trailer 6 Functional Group Header/Trailer Specifications Seg Data Element Name Usage Comments Expected Value GS Functional Group Header R GS01 Functional Identifier Code R Valid values: 'HC' Health Care Claims (837) Use 'HC' Health Care Claims (837) GS02 Application Sender's Code R The sender defines this value. GS03 Application Receiver's Code R This field identifies how the file was received by ABH. Use 'EDI' for electronic transfer of data. GS04 Date R Date format CCYYMMDD GS05 Time R Time format HHMM. GS06 Group Control Number R The group control number in GS06 must be the same as the associated group trailer element (GE02). GS07 Responsible Agency Code R Valid values: 'X' Accredited Standards Committee X12 Use 'X' Accredited Standards Committee X12 GS08 Version/Release Industry ID Code R Valid values: '005010X222A1' - Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003. '005010X223A2' - Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003. Use the current standard approved for publication by ASC X12. Seg Data Element Name Usage Comments Expected Value GE Functional Group Trailer R GE01 Number of Transaction Sets IncludedR Count of the number of transaction sets in the functional group. Only similar transaction sets may be included in the functional group. GE02 Group Control Number R The group control number in GE02 must match that sent in the group header (GS06). The group control numbers in the GE and GS segments will be compared. If the numbers do not match the file will be rejected. Header Trailer 7 837 Professional Claim Transaction Specifications Seg Data Element Name Usage Comments Expected Value BHT Beginning of Hierarchical Transaction R BHT02 Transaction Set Purpose Code R Valid values: '00' Original '18' Reissue Case Use '00' Original. BHT06 Transaction Type Code R Use 'CH' for claims NM1 Submitter Name R NM109 Submitter Primary Identifier R This element contains the ETIN (Electronic Transaction Identifier Number). Use the ABH Submitter ID. NM1 Receiver Name R NM103 Receiver Name R Use 'Advanced Behavioral Health, Inc.' NM109 Receiver Primary Identifier R This element contains the ETIN (Electronic Transaction Identifier Number). Use 'ABH'. PRV Billing / Pay-To Provider Specialty Information R PRV02 Provider Specialty Code Qualifier R Use 'PXC' PRV03 Provider Taxonomy Code R Send the providers taxonomy code. NM1 Billing Provider Name R NM108 Billing Provider Identification Code Qualifier R Use 'XX' NM109 Billing Provider Identifier R Send the Provider's National Provider ID (NPI) N4 Billing Provider City/State/Zip Code R N403 Billing Provider Zip Code R Send the Provider's 9-digit zip code. REF Billing Provider Secondary Identification S When NPI is submitted in NM108/109, the provider must send either their EIN or SSN in the REF loop. REF01 Reference Identification Qualifier R Use: 'EI' Tax ID (to indicate the provider's EIN) 'SY' SSN (to indicate the provider's SSN) REF02 Billing Provider Additional Identifier R Send the Provider's EIN/SSN NM1 Subscriber Name R NM108 Identification Code Qualifier S Required if the subscriber is a person (NM102 = 1). Also required if the subscriber is the patient. Use 'MI' Member Identification Number. NM109 Subscriber Primary Identifier S Use the client's EMS ID. NM1 Payer Name R NM103 Payer Name R Destination Payer Name Use 'Advanced Behavioral Health, Inc.' NM108 Identification Code Qualifier R Use 'PI' Payer Identifier NM109 Payer Identifier R Destination Payer Identifier Use 'ABH'. CLM Claim Information R CLM01 Claims Submitter's Identifier R Patient's Account Number entered here will be returned on the EOB. NM1 Referring Provider Name S NM108 Identification Code Qualifier S Use 'XX'. NM109 Identification Code S Use the National Provider ID (NPI) of the referring provider. REF Referring Provider Secondary Identification S REF01 Reference Identification Qualifier R Required if a secondary number is necessary to identify the provider. The primary identifier should be sent in NM108/109 in this loop. Use 'G2' REF02 Referring Provider Secondary Identification R Header Loop 1000A - Submitter Name Loop 1000B - Receiver Name Loop 2010AA - Billing Provider Name Loop 2000A - Billing / Pay-To Provider Specialty Information Loop 2010BA - Subscriber Name Loop 2010BB - Payer Name Loop 2300 - Claim Information	837 Health Care Claim Companion Guide Rev 12 2011.pdf
Element Name Usage Comments Expected Value GE Functional Group Trailer R GE01 Number of Transaction Sets IncludedR Count of the number of transaction sets in the functional group. Only similar transaction sets may be included in the functional group. GE02 Group Control Number R The group control number in GE02 must match that sent in the group header (GS06). The group control numbers in the GE and GS segments will be compared. If the numbers do not match the file will be rejected. Header Trailer 7 837 Professional Claim Transaction Specifications Seg Data Element Name Usage Comments Expected Value BHT Beginning of Hierarchical Transaction R BHT02 Transaction Set Purpose Code R Valid values: '00' Original '18' Reissue Case Use '00' Original. BHT06 Transaction Type Code R Use 'CH' for claims NM1 Submitter Name R NM109 Submitter Primary Identifier R This element contains the ETIN (Electronic Transaction Identifier Number). Use the ABH Submitter ID. NM1 Receiver Name R NM103 Receiver Name R Use 'Advanced Behavioral Health, Inc.' NM109 Receiver Primary Identifier R This element contains the ETIN (Electronic Transaction Identifier Number). Use 'ABH'. PRV Billing / Pay-To Provider Specialty Information R PRV02 Provider Specialty Code Qualifier R Use 'PXC' PRV03 Provider Taxonomy Code R Send the providers taxonomy code. NM1 Billing Provider Name R NM108 Billing Provider Identification Code Qualifier R Use 'XX' NM109 Billing Provider Identifier R Send the Provider's National Provider ID (NPI) N4 Billing Provider City/State/Zip Code R N403 Billing Provider Zip Code R Send the Provider's 9-digit zip code. REF Billing Provider Secondary Identification S When NPI is submitted in NM108/109, the provider must send either their EIN or SSN in the REF loop. REF01 Reference Identification Qualifier R Use: 'EI' Tax ID (to indicate the provider's EIN) 'SY' SSN (to indicate the provider's SSN) REF02 Billing Provider Additional Identifier R Send the Provider's EIN/SSN NM1 Subscriber Name R NM108 Identification Code Qualifier S Required if the subscriber is a person (NM102 = 1). Also required if the subscriber is the patient. Use 'MI' Member Identification Number. NM109 Subscriber Primary Identifier S Use the client's EMS ID. NM1 Payer Name R NM103 Payer Name R Destination Payer Name Use 'Advanced Behavioral Health, Inc.' NM108 Identification Code Qualifier R Use 'PI' Payer Identifier NM109 Payer Identifier R Destination Payer Identifier Use 'ABH'. CLM Claim Information R CLM01 Claims Submitter's Identifier R Patient's Account Number entered here will be returned on the EOB. NM1 Referring Provider Name S NM108 Identification Code Qualifier S Use 'XX'. NM109 Identification Code S Use the National Provider ID (NPI) of the referring provider. REF Referring Provider Secondary Identification S REF01 Reference Identification Qualifier R Required if a secondary number is necessary to identify the provider. The primary identifier should be sent in NM108/109 in this loop. Use 'G2' REF02 Referring Provider Secondary Identification R Header Loop 1000A - Submitter Name Loop 1000B - Receiver Name Loop 2010AA - Billing Provider Name Loop 2000A - Billing / Pay-To Provider Specialty Information Loop 2010BA - Subscriber Name Loop 2010BB - Payer Name Loop 2300 - Claim Information Loop 2310A - Referring Provider Name 8 837 Professional Claim Transaction Specifications Seg Data Element Name Usage Comments Expected Value NM1 Rendering Provider Secondary Identification S NM108 Identification Qualifier R Use 'XX'. NM109 Rendering Provider Identification R Use the National Provider ID (NPI) of the rendering provider. SV1 Professional Service R SV101 Composite Medical Procedure Identifier R SV101-1 Product/Service ID Qualifier R Use 'HC' Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes. SV101-3 SV101-4 SV101-5 SV101-6 Procedure Modifier S SV104 Quantity S Use whole number unit values. DTP Date - Service Date R DTP02 Date/Time Period Qualifier R Valid values: 'D8' Single Date (CCYYMMDD) 'RD8' Range of Dates Use 'RD8' to specify a range of dates. The from and thru service dates should be sent for each service line. Loop 2400 - Service Line Loop 2310B - Rendering Provider Name 9 837 Institutional Claim Transaction Specifications Seg Data Element Name Usage Comments Expected Value BHT Beginning of Hierarchical Transaction R BHT02 Transaction Set Purpose Code R Valid values: '00' Original '18' Reissue Case Use '00' Original. BHT06 Transaction Type Code R Use 'CH' for claims NM1 Submitter Name R NM109 Submitter Primary Identifier R This element contains the ETIN (Electronic Transaction Identifier Number). Use the ABH Submitter ID. NM1 Receiver Name R NM103 Receiver Name R Use 'Advanced Behavioral Health, Inc.' NM109 Receiver Primary Identifier R This element contains the ETIN (Electronic Transaction Identifier Number). Use 'ABH'. PRV Billing / Pay-To Provider Specialty Information R PRV02 Provider Specialty Code Qualifier R Use 'PXC' PRV03 Provider Taxonomy Code R Send the providers taxonomy code. NM1 Billing Provider Name R NM108 Billing Provider Identification Code Qualifier R Use 'XX' NM109 Billing Provider Identifier R Send the Provider's National Provider ID (NPI) N4 Billing Provider City/State/Zip Code R N403 Billing Provider Zip Code R Send the Provider's 9-digit zip code. REF Billing Provider Secondary Identification S When NPI is submitted in NM108/109, the provider must send their EIN in the REF loop. REF01 Reference Identification Qualifier R Use: 'EI' Tax ID (to indicate the provider's EIN) REF02 Billing Provider Additional Identifier R Send the Provider's EIN NM1 Subscriber Name R NM108 Identification Code Qualifier S Required if the subscriber is a person (NM102 = 1). Also required if the subscriber is the patient. Use 'MI' Member Identification Number. NM109 Subscriber Primary Identifier S Use the client's EMS ID. NM1 Payer Name R NM103 Payer Name R Destination Payer Name Use 'Advanced Behavioral Health, Inc.' NM108 Identification Code Qualifier R Use 'PI' Payer Identifier NM109 Payer Identifier R Destination Payer Identifier Use 'ABH'. CLM Claim Information R CLM01 Claims Submitter's Identifier R Patient's Account Number entered here will be returned on the EOB. CLM05 Health Care Service Location Information R CLM05-3 Claim Frequency Type Code R UB-92 Type of Bill. Valid values: '1' - Admit through Discharge Claim '2' - Interim - First Claim '3' - Interim - Continuing Claim '4' - Interim - Last Claim '5' - Late Charge Only Use '1', '2', '3', '4', or '5' REF Original Reference Number (ICN/DCN) S REF02 Original Reference Number (ICN/DCN) R When submitting an Original Reference Number use the number with the prefix of 'RC'. HI Principal Procedure Information S HI01 Health Care Code Information R HI01-1 Code List Qualifier R Use 'BR' Health Care Financing Administration Common Procedural Coding System Principal Procedure. HI Other Procedure Information S HI01 Health Care Code Information R HI01-1 Code List Qualifier R Use 'BQ' Health Care Financing Administration Common Procedural Coding System. Loop 2010BA - Subscriber Name Loop 2010BB - Payer Name Header Loop 1000A - Submitter Name Loop 1000B - Receiver Name Loop 2010AA - Billing Provider Name Loop 2000A - Billing / Pay-To Provider Specialty Information Loop 2300 - Claim Information 10 837 Institutional Claim Transaction Specifications Seg Data Element Name Usage Comments Expected Value SV2 Institutional Service Line R SV202 Composite Medical Procedure Identifier S SV202-1 Product/Service ID Qualifier R Use 'HC' Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes. SV202-3 SV202-4 SV202-5 SV202-6 Procedure Modifier S SV205 Quantity S Use whole number unit values. DTP Date - Service Date R DTP02 Date/Time Period Qualifier R Valid values: 'D8' Single Date (CCYYMMDD) 'RD8' Range of Dates Use 'RD8' to specify a range of dates. The from and thru service dates should be sent for each service line. Loop 2400 - Service Line Number 11	837 Health Care Claim Companion Guide Rev 12 2011.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.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.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.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.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.pdf
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 837 Health Care Claim: Institutional (X223A3) 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 Transaction Set (837) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment. For purposes of this standard, providers of health care products or services may include entities such as physicians, hospitals and other medical facilities or suppliers, dentists, and pharmacies, and entities providing medical information to meet regulatory requirements. The payer refers to a third party entity that pays claims or administers the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups. A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific health care/insurance industry segment. Delimiters ~ Segment * Element > Component ^ Repetition 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 1/285 View the latest version of this implementation guide as an interactive webpage https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional- x223a3/01H25JDXFJR748R6M871MGNNCJ POWERED BY Build EDI implementation guides at stedi.com 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 2/285 Overview ISA - Interchange Control Header Max use 1 Required GS - Functional Group Header Max use 1 Required Heading ST 0050 Transaction Set Header Max use 1 Required BHT 0100 Beginning of Hierarchical Transaction Max use 1 Required Submitter Name Loop NM1 0200 Submitter Name Max use 1 Required PER 0450 Submitter EDI Contact Information Max use 2 Required Receiver Name Loop NM1 0200 Receiver Name Max use 1 Required Detail Billing Provider Hierarchical Level Loop HL 0010 Hierarchical Level Max use 1 Required PRV 0030 Billing Provider Specialty Information Max use 1 Optional Billing Provider Name Loop NM1 0150 Billing Provider Name Max use 1 Required N3 0250 Billing Provider Address Max use 1 Required N4 0300 Billing Provider City, State, ZIP Code Max use 1 Required REF 0350 Billing Provider Tax Identification Max use 1 Required PER 0400 Billing Provider Contact Information Max use 2 Optional Pay-to Address Name Loop NM1 0150 Pay-to Address Name Max use 1 Required N3 0250 Pay-to Address - ADDRESS Max use 1 Required N4 0300 Pay-To Address City, State, ZIP Code Max use 1 Required Subscriber Hierarchical Level Loop HL 0010 Hierarchical Level Max use 1 Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 3/285 SBR 0050 Subscriber Information Max use 1 Required Subscriber Name Loop NM1 0150 Subscriber Name Max use 1 Required N3 0250 Subscriber Address Max use 1 Optional N4 0300 Subscriber City, State, ZIP Code Max use 1 Optional DMG 0320 Subscriber Demographic Information Max use 1 Optional REF 0350 Property and Casualty Claim Number Max use 1 Optional Payer Name Loop NM1 0150 Payer Name Max use 1 Required N3 0250 Payer Address Max use 1 Optional N4 0300 Payer City, State, ZIP Code Max use 1 Optional REF 0350 Billing Provider Secondary Identification Max use 1 Optional Claim Information Loop CLM 1300 Claim Information Max use 1 Required DTP 1350 Admission Date/Hour Max use 1 Optional DTP 1350 Date - Repricer Received Date Max use 1 Optional DTP 1350 Discharge Hour Max use 1 Optional DTP 1350 Statement Dates Max use 1 Required CL1 1400 Institutional Claim Code Max use 1 Required PWK 1550 Claim Supplemental Information Max use 10 Optional AMT 1750 Patient Estimated Amount Due Max use 1 Optional REF 1800 Adjusted Repriced Claim Number Max use 1 Optional REF 1800 Auto Accident State Max use 1 Optional REF 1800 Claim Identifier For Transmission Intermediaries Max use 1 Optional REF 1800 Demonstration Project Identifier Max use 1 Optional REF 1800 Investigational Device Exemption Number Max use 5 Optional REF 1800 Medical Record Number Max use 1 Optional REF 1800 Payer Claim Control Number Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 4/285 REF 1800 Peer Review Organization (PRO) Approval Number Max use 1 Optional REF 1800 Prior Authorization Max use 1 Optional REF 1800 Referral Number Max use 1 Optional REF 1800 Repriced Claim Number Max use 1 Optional REF 1800 Service Authorization Exception Code Max use 1 Optional K3 1850 File Information Max use 10 Optional NTE 1900 Billing Note Max use 1 Optional NTE 1900 Claim Note Max use 10 Optional CRC 2200 EPSDT Referral Max use 1 Optional HI 2310 Admitting Diagnosis Max use 1 Optional HI 2310 Condition Information Max use 2 Optional HI 2310 Diagnosis Related Group (DRG) Information Max use 1 Optional HI 2310 External Cause of Injury Max use 1 Optional HI 2310 Occurrence Information Max use 2 Optional HI 2310 Occurrence Span Information Max use 2 Optional HI 2310 Other Diagnosis Information Max use 2 Optional HI 2310 Other Procedure Information Max use 2 Optional HI 2310 Patient's Reason For Visit Max use 1 Optional HI 2310 Principal Diagnosis Max use 1 Required HI 2310 Principal Procedure Information Max use 1 Optional HI 2310 Treatment Code Information Max use 2 Optional HI 2310 Value Information Max use 2 Optional HCP 2410 Claim Pricing/Repricing Information Max use 1 Optional Attending Provider Name Loop NM1 2500 Attending Provider Name Max use 1 Required PRV 2550 Attending Provider Specialty Information Max use 1 Optional REF 2710 Attending Provider Secondary Identification Max use 4 Optional Operating Physician Name Loop 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 5/285 NM1 2500 Operating Physician Name Max use 1 Required REF 2710 Operating Physician Secondary Identification Max use 4 Optional Other Operating Physician Name Loop NM1 2500 Other Operating Physician Name Max use 1 Required REF 2710 Other Operating Physician Secondary Identification Max use 4 Optional Rendering Provider Name Loop NM1 2500 Rendering Provider Name Max use 1 Required REF 2710 Rendering Provider Secondary Identification Max use 4 Optional Service Facility Location Name Loop NM1 2500 Service Facility Location Name Max use 1 Required N3 2650 Service Facility Location Address Max use 1 Required N4 2700 Service Facility Location City, State, ZIP Code Max use 1 Required REF 2710 Service Facility Location Secondary Identification Max use 3 Optional Referring Provider Name Loop NM1 2500 Referring Provider Name Max use 1 Required Other Subscriber Information Loop SBR 2900 Other Subscriber Information Max use 1 Required CAS 2950 Claim Level Adjustments Max use 5 Optional AMT 3000 Coordination of Benefits (COB) Payer Paid Amount Max use 1 Optional AMT 3000 Coordination of Benefits (COB) Total Non- Covered Amount Max use 1 Optional AMT 3000 Remaining Patient Liability Max use 1 Optional OI 3100 Other Insurance Coverage Information Max use 1 Required MIA 3150 Inpatient Adjudication Information Max use 1 Optional MOA 3200 Outpatient Adjudication Information Max use 1 Optional Other Subscriber Name Loop NM1 3250 Other Subscriber Name Max use 1 Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 6/285 N3 3320 Other Subscriber Address Max use 1 Optional N4 3400 Other Subscriber City, State, ZIP Code Max use 1 Optional REF 3550 Other Subscriber Secondary Identification Max use 2 Optional Other Payer Name Loop NM1 3250 Other Payer Name Max use 1 Required N3 3320 Other Payer Address Max use 1 Optional N4 3400 Other Payer City, State, ZIP Code Max use 1 Optional DTP 3500 Claim Check or Remittance Date Max use 1 Optional REF 3550 Other Payer Claim Adjustment Indicator Max use 1 Optional REF 3550 Other Payer Claim Control Number Max use 1 Optional REF 3550 Other Payer Prior Authorization Number Max use 1 Optional REF 3550 Other Payer Referral Number Max use 1 Optional REF 3550 Other Payer Secondary Identifier Max use 2 Optional Service Line Number Loop LX 3650 Service Line Number Max use 1 Required SV2 3750 Institutional Service Line Max use 1 Required PWK 4200 Line Supplemental Information Max use 10 Optional DTP 4550 Date - Service Date Max use 1 Optional REF 4700 Adjusted Repriced Line Item Reference Number Max use 1 Optional REF 4700 Line Item Control Number Max use 1 Optional REF 4700 Repriced Line Item Reference Number Max use 1 Optional AMT 4750 Facility Tax Amount Max use 1 Optional AMT 4750 Service Tax Amount Max use 1 Optional NTE 4850 Third Party Organization Notes Max use 1 Optional HCP 4920 Line Pricing/Repricing Information Max use 1 Optional Drug Identification Loop LIN 4930 Drug Identification Max use 1 Required CTP 4940 Drug Quantity Max use 1 Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 7/285 REF 4950 Prescription or Compound Drug Association Number Max use 1 Optional Operating Physician Name Loop NM1 5000 Operating Physician Name Max use 1 Required REF 5250 Operating Physician Secondary Identification Max use 20 Optional Other Operating Physician Name Loop NM1 5000 Other Operating Physician Name Max use 1 Required REF 5250 Other Operating Physician Secondary Identification Max use 20 Optional Rendering Provider Name Loop NM1 5000 Rendering Provider Name Max use 1 Required REF 5250 Rendering Provider Secondary Identification Max use 20 Optional Referring Provider Name Loop NM1 5000 Referring Provider Name Max use 1 Required REF 5250 Referring Provider Secondary Identification Max use 20 Optional Line Adjudication Information Loop SVD 5400 Line Adjudication Information Max use 1 Required CAS 5450 Line Adjustment Max use 5 Optional DTP 5500 Line Check or Remittance Date Max use 1 Required AMT 5505 Remaining Patient Liability Max use 1 Optional SE 5550 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 8/285 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 XXXXXXXXXXXXXXXXXX2501310655^0050100000000 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 9/285 Identification code published by the sender for other parties to use as	CGS Medicare 837 Health Care Claim_ Institutional.pdf
Item Reference Number Max use 1 Optional AMT 4750 Facility Tax Amount Max use 1 Optional AMT 4750 Service Tax Amount Max use 1 Optional NTE 4850 Third Party Organization Notes Max use 1 Optional HCP 4920 Line Pricing/Repricing Information Max use 1 Optional Drug Identification Loop LIN 4930 Drug Identification Max use 1 Required CTP 4940 Drug Quantity Max use 1 Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 7/285 REF 4950 Prescription or Compound Drug Association Number Max use 1 Optional Operating Physician Name Loop NM1 5000 Operating Physician Name Max use 1 Required REF 5250 Operating Physician Secondary Identification Max use 20 Optional Other Operating Physician Name Loop NM1 5000 Other Operating Physician Name Max use 1 Required REF 5250 Other Operating Physician Secondary Identification Max use 20 Optional Rendering Provider Name Loop NM1 5000 Rendering Provider Name Max use 1 Required REF 5250 Rendering Provider Secondary Identification Max use 20 Optional Referring Provider Name Loop NM1 5000 Referring Provider Name Max use 1 Required REF 5250 Referring Provider Secondary Identification Max use 20 Optional Line Adjudication Information Loop SVD 5400 Line Adjudication Information Max use 1 Required CAS 5450 Line Adjustment Max use 5 Optional DTP 5500 Line Check or Remittance Date Max use 1 Required AMT 5505 Remaining Patient Liability Max use 1 Optional SE 5550 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 8/285 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 XXXXXXXXXXXXXXXXXX2501310655^0050100000000 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 9/285 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 10/285 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 11/285 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GSHCXXXXXXXXXX2025013021280000000X005010X 223A3~ Max use 1 Required GS-01 479 Functional Identifier Code Identifier (ID) Required Code identifying a group of application related transaction sets HC Health Care Claim (837) 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 12/285 T Transportation Data Coordinating Committee (TDCC) 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 005010X223A3 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 13/285 Heading ST 0050 Heading > ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST8370001005010X223A3~ 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). 837 Health Care Claim 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 Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges. ST-03 1705 Version, Release, or Industry Identifier String (AN) Required Reference assigned to identify Implementation Convention The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08. Usage notes This element must be populated with the guide identifier named in Section 1.2. This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is used at translation time. 005010X223A3 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 14/285 BHT 0100 Heading > BHT Beginning of Hierarchical Transaction To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time Usage notes The second example denotes the case where the entire transaction set contains ENCOUNTERS. Example BHT001900XXX202501302237*CH~ Max use 1 Required BHT-01 1005 Hierarchical Structure Code Identifier (ID) Required Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set 0019 Information Source, Subscriber, Dependent BHT-02 353 Transaction Set Purpose Code Identifier (ID) Required Code identifying purpose of transaction set Usage notes BHT02 is intended to convey the electronic transmission status of the 837 batch contained in this ST-SE envelope. The terms "original" and "reissue" refer to the electronic transmission status of the 837 batch, not the billing status. 00 Original Original transmissions are transmissions which have never been sent to the receiver. BHT-03 127 Originator Application Transaction Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system. Usage notes The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number. This field is limited to 30 characters. BHT-04 373 Transaction Set Creation Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 15/285 year BHT04 is the date the transaction was created within the business application system. Usage notes This is the date that the original submitter created the claim file from their business application system. BHT-05 337 Transaction Set Creation Time Time (TM) Required HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99) BHT05 is the time the transaction was created within the business application system. Usage notes This is the time that the original submitter created the claim file from their business application system. BHT-06 640 Claim Identifier Identifier (ID) Required Code specifying the type of transaction CH Chargeable Use CH when the transaction contains only fee for service claims or claims with at least one chargeable line item. If it is not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters, use CH. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 16/285 1000A Submitter Name Loop Max 1 Required	CGS Medicare 837 Health Care Claim_ Institutional.pdf
translation time. 005010X223A3 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 14/285 BHT 0100 Heading > BHT Beginning of Hierarchical Transaction To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time Usage notes The second example denotes the case where the entire transaction set contains ENCOUNTERS. Example BHT001900XXX202501302237CH~ Max use 1 Required BHT-01 1005 Hierarchical Structure Code Identifier (ID) Required Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set 0019 Information Source, Subscriber, Dependent BHT-02 353 Transaction Set Purpose Code Identifier (ID) Required Code identifying purpose of transaction set Usage notes BHT02 is intended to convey the electronic transmission status of the 837 batch contained in this ST-SE envelope. The terms "original" and "reissue" refer to the electronic transmission status of the 837 batch, not the billing status. 00 Original Original transmissions are transmissions which have never been sent to the receiver. BHT-03 127 Originator Application Transaction Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system. Usage notes The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number. This field is limited to 30 characters. BHT-04 373 Transaction Set Creation Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 15/285 year BHT04 is the date the transaction was created within the business application system. Usage notes This is the date that the original submitter created the claim file from their business application system. BHT-05 337 Transaction Set Creation Time Time (TM) Required HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99) BHT05 is the time the transaction was created within the business application system. Usage notes This is the time that the original submitter created the claim file from their business application system. BHT-06 640 Claim Identifier Identifier (ID) Required Code specifying the type of transaction CH Chargeable Use CH when the transaction contains only fee for service claims or claims with at least one chargeable line item. If it is not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters, use CH. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 16/285 1000A Submitter Name Loop Max 1 Required Variants (all may be used) Receiver Name Loop NM1 0200 Heading > Submitter Name Loop > NM1 Submitter Name To supply the full name of an individual or organizational entity Usage notes The submitter is the entity responsible for the creation and formatting of this transaction. Example NM1412XXXXXX*46XXXX~ 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 41 Submitter 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 Submitter Last or Organization Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Submitter First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Submitter Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial Usage notes 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 17/285 Medicare does not support the submission of foreign currency. NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) 46 Electronic Transmitter Identification Number (ETIN) Established by trading partner agreement NM1-09 67 Submitter Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes 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. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 18/285 PER 0450 Heading > Submitter Name Loop > PER Submitter EDI 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 must always include 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. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". The contact information in this segment identifies the person in the submitter organization who deals with data transmission issues. If data transmission problems arise, this is the person to contact in the submitter organization. There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions. Example PERICXXXXXEMXXXXEMXFXX~ If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required Max use 2 Required 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-02 93 Submitter 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 Communication Number Min 1 Max 256 String (AN) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 19/285 1000A Submitter Name Loop end 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 FX Facsimile TE Telephone PER-06 364 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 FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 20/285 1000B Receiver Name Loop Max 1 Required Variants (all may be used) Submitter Name Loop NM1 0200 Heading > Receiver Name Loop > NM1 Receiver Name To supply the full name of an individual or organizational entity Example NM1402XXX***46XX~ 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 40 Receiver 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 Receiver 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) 46 Electronic Transmitter Identification Number (ETIN) NM1-09 67 Receiver Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 21/285 1000B Receiver Name Loop end Heading end 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. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 22/285 Detail 2000A Billing Provider Hierarchical Level Loop Max >1 Required HL 0010 Detail > Billing Provider Hierarchical Level Loop > HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL1201~ Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 20 Information Source HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1 Additional Subordinate HL Data Segment in This Hierarchical Structure. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 23/285 PRV 0030 Detail > Billing Provider Hierarchical Level Loop > PRV Billing Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when the payer's adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send. Example PRVBIPXC*XX~ Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider BI Billing PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 24/285 2010AA Billing Provider Name Loop Max 1 Required Variants (all may be used) Pay-to Address Name Loop NM1 0150 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > NM1 Billing Provider Name To supply the full name of an individual or organizational entity Usage notes Beginning on the NPI compliance date: When the Billing Provider is an organization health care provider, the organization health care provider's NPI or its subpart's NPI is reported in NM109. When a health care provider organization has determined that it needs to enumerate its subparts, it will report the NPI of a subpart as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be the same identifier sent to any trading partner. For additional explanation, see section 1.10.3 Organization Health Care Provider Subpart Presentation. Prior to the NPI compliance date, proprietary	CGS Medicare 837 Health Care Claim_ Institutional.pdf
to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 20 Information Source HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1 Additional Subordinate HL Data Segment in This Hierarchical Structure. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 23/285 PRV 0030 Detail > Billing Provider Hierarchical Level Loop > PRV Billing Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when the payer's adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send. Example PRVBIPXCXX~ Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider BI Billing PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 24/285 2010AA Billing Provider Name Loop Max 1 Required Variants (all may be used) Pay-to Address Name Loop NM1 0150 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > NM1 Billing Provider Name To supply the full name of an individual or organizational entity Usage notes Beginning on the NPI compliance date: When the Billing Provider is an organization health care provider, the organization health care provider's NPI or its subpart's NPI is reported in NM109. When a health care provider organization has determined that it needs to enumerate its subparts, it will report the NPI of a subpart as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be the same identifier sent to any trading partner. For additional explanation, see section 1.10.3 Organization Health Care Provider Subpart Presentation. Prior to the NPI compliance date, proprietary identifiers necessary for the receiver to identify the Billing Provider entity are to be reported in the REF segment of Loop ID- 2010BB. The Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099 purposes must be reported in the REF segment of this loop. When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment. The TIN to be used for 1099 purposes must be reported in the REF (Tax Identification Number) segment of this loop. Example NM1852XXXX****XXXXXXX~ If either Identification Code Qualifier (NM1-08) or Billing Provider 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 85 Billing Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 25/285 NM1-03 1035 Billing Provider Organizational Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Billing Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 26/285 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N3 Billing Provider Address To specify the location of the named party Usage notes The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-To Address Loop (Loop ID-2010AB), if necessary. Example N3XXXXX~ Max use 1 Required N3-01 166 Billing Provider Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Billing Provider Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 27/285 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N4 Billing Provider City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXX~ Only one of Billing Provider State or Province 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 Billing Provider 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 Billing Provider State or Province 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 Billing Provider 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 When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 28/285 Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 29/285 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF Billing Provider Tax Identification To specify identifying information Usage notes This is the tax identification number (TIN) of the entity to be paid for the submitted services. Example REFEIX~ Max use 1 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. REF-02 127 Billing Provider Tax Identification 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 30/285 PER 0400 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > PER Billing Provider Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when this information is different than that contained in the Loop ID-1000A - Submitter PER segment. 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 must always include 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. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions. Example PERICXXXFXXXXXXXFXXEMXXXX~ If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (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 IC Information Contact PER-02 93 Billing Provider 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 Communication Number Min 1 Max 256 String (AN) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 31/285 2010AA Billing Provider Name Loop end 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 FX Facsimile TE Telephone PER-06 364 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 FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 32/285 2010AB Pay-to Address Name Loop Max 1 Optional Variants (all may be used) Billing Provider Name Loop NM1 0150 Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > NM1 Pay-to Address Name To supply the full name of an individual or organizational entity Usage notes Required when the address for payment is different than that of the Billing Provider. If not required by this implementation guide, do not send.; The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address. There are no applicable identifiers for Pay-To Address information. Example NM1872~ 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 87 Pay-to Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 33/285 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > N3 Pay-to Address - ADDRESS To specify the location of the named party Example N3XXXXXXXXXXXX~ Max use 1 Required N3-01 166 Pay-To Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Pay-To Address Line Min 1 Max 55 String (AN) Optional Address information	CGS Medicare 837 Health Care Claim_ Institutional.pdf
extension, such as "ext" or "x-". There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions. Example PERICXXXFXXXXXXXFXXEMXXXX~ If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (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 IC Information Contact PER-02 93 Billing Provider 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 Communication Number Min 1 Max 256 String (AN) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 31/285 2010AA Billing Provider Name Loop end 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 FX Facsimile TE Telephone PER-06 364 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 FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 32/285 2010AB Pay-to Address Name Loop Max 1 Optional Variants (all may be used) Billing Provider Name Loop NM1 0150 Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > NM1 Pay-to Address Name To supply the full name of an individual or organizational entity Usage notes Required when the address for payment is different than that of the Billing Provider. If not required by this implementation guide, do not send.; The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address. There are no applicable identifiers for Pay-To Address information. Example NM1872~ 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 87 Pay-to Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 33/285 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > N3 Pay-to Address - ADDRESS To specify the location of the named party Example N3XXXXXXXXXXXX~ Max use 1 Required N3-01 166 Pay-To Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Pay-To Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 34/285 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > N4 Pay-To Address City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXXX~ Only one of Pay-to Address 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 Pay-to Address 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 Pay-to Address 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 Pay-to Address 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. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 35/285 2010AB Pay-to Address Name Loop end 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 36/285 2000B Subscriber Hierarchical Level Loop Max >1 Required HL 0010 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL21220~ Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-02 734 Hierarchical Parent ID Number Min 1 Max 12 String (AN) Required Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 22 Subscriber HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 37/285 0 No Subordinate HL Segment in This Hierarchical Structure. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 38/285 SBR 0050 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > SBR Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Example SBRP18XXXXXXXXX****OF~ Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. P Primary S Secondary T Tertiary SBR-02 1069 Individual Relationship Code Identifier (ID) Optional Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. Usage notes For Medicare, the subscriber is always the same as the patient. 18 Self SBR-03 127 Subscriber Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop ID-2010BA-NM109. SBR-04 93 Subscriber Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 39/285 Code identifying type of claim Usage notes For Medicare, the subscriber is always the same as the patient. 11 Other Non-Federal Programs 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance 16 Health Maintenance Organization (HMO) Medicare Risk 17 Dental Maintenance Organization AM Automobile Medical BL Blue Cross/Blue Shield CH Champus CI Commercial Insurance Co. DS Disability FI Federal Employees Program HM Health Maintenance Organization LM Liability Medical MA Medicare Part A MB Medicare Part B MC Medicaid OF Other Federal Program Use code OF when submitting Medicare Part D claims. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 40/285 2010BA Subscriber Name Loop Max 1 Required Variants (all may be used) Payer Name Loop NM1 0150 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > NM1 Subscriber Name To supply the full name of an individual or organizational entity Usage notes In worker's compensation or other property and casualty claims, the "subscriber" may be a non-person entity (for example, the employer). However, this varies by state. Example NM1IL1XXXXXXXXXX*XXMI*XXXXX~ If either Identification Code Qualifier (NM1-08) or Subscriber Primary 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 IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Subscriber Last Name Min 1 Max 60 String (AN) Required 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 Individual middle name or initial Usage notes 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 41/285 The first position must be alphabetic (A-Z). NM1-07 1039 Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes Examples: I, II, III, IV, Jr, Sr This data element is used only to indicate generation or patronymic. 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 The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.) MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Subscriber Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes 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”. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 42/285 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N3 Subscriber Address To specify the location of the named party Usage notes Required when the patient is	CGS Medicare 837 Health Care Claim_ Institutional.pdf
Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > NM1 Subscriber Name To supply the full name of an individual or organizational entity Usage notes In worker's compensation or other property and casualty claims, the "subscriber" may be a non-person entity (for example, the employer). However, this varies by state. Example NM1IL1XXXXXXXXXXXXMIXXXXX~ If either Identification Code Qualifier (NM1-08) or Subscriber Primary 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 IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Subscriber Last Name Min 1 Max 60 String (AN) Required 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 Individual middle name or initial Usage notes 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 41/285 The first position must be alphabetic (A-Z). NM1-07 1039 Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes Examples: I, II, III, IV, Jr, Sr This data element is used only to indicate generation or patronymic. 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 The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.) MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Subscriber Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes 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”. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 42/285 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N3 Subscriber Address To specify the location of the named party Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example N3XXXXXXXXXXXX~ Max use 1 Optional N3-01 166 Subscriber Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Subscriber Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 43/285 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N4 Subscriber City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example N4XXXXXXXXXXXXXXXXX~ Only one of Subscriber 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 Subscriber 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 Subscriber 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 Subscriber 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 44/285 Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 45/285 DMG 0320 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > DMG Subscriber Demographic Information To supply demographic information Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example DMGD8XF~ Max use 1 Optional DMG-01 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD DMG-02 1251 Subscriber Birth Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times DMG02 is the date of birth. Usage notes Must not be a future date. DMG-03 1068 Subscriber Gender Code Identifier (ID) Required Code indicating the sex of the individual F Female M Male U Unknown 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 46/285 2010BA Subscriber Name Loop end REF 0350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF Property and Casualty Claim Number To specify identifying information Usage notes This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.; This segment is not a HIPAA requirement as of this writing. Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send. Example REFY4XXX~ Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Y4 Agency Claim Number REF-02 127 Property Casualty Claim 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 47/285 2010BB Payer Name Loop Max 1 Required Variants (all may be used) Subscriber Name Loop NM1 0150 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > NM1 Payer Name To supply the full name of an individual or organizational entity Usage notes This is the destination payer. For the purposes of this implementation the term payer is synonymous with several other terms, such as, repricer and third party administrator. Example NM1PR2X***PIXXXXX~ 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 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 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) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 48/285 Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification NM1-09 67 Payer Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 49/285 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N3 Payer Address To specify the location of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N3XXXXXXXXXX~ Max use 1 Optional 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 50/285 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N4 Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N4XXXXXXXXXXX~ 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 Optional 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. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 51/285 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 52/285 2010BB Payer Name Loop end REF 0350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > REF Billing Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated NPI Implementation Date when an additional identification number is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in Loop 2010AA is not used and an identification number other	CGS Medicare 837 Health Care Claim_ Institutional.pdf
Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 49/285 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N3 Payer Address To specify the location of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N3XXXXXXXXXX~ Max use 1 Optional 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 50/285 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N4 Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N4XXXXXXXXXXX~ 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 Optional 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. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 51/285 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 52/285 2010BB Payer Name Loop end REF 0350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > REF Billing Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated NPI Implementation Date when an additional identification number is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in Loop 2010AA is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REFLUXXXXX~ Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Billing 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 53/285 2300 Claim Information Loop Max 100 Optional CLM 1300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CLM Claim Information To specify basic data about the claim Usage notes The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA- IEA. Willing trading partners can agree to set limits higher. For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this, the claim information is said to "float." Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber/Patient HL Segment explanation in section 1.4.3.2.2.1 for details. Example CLMXXX0000*X>A>XAYY**********4~ Max use 1 Required CLM-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 The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim. When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN/DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies. The maximum number of characters to be supported for this field is `20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system. CLM-02 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 54/285 Monetary amount CLM02 is the total amount of all submitted charges of service segments for this claim. Usage notes The Total Claim Charge Amount must be greater than or equal to zero. The total claim charge amount must balance to the sum of all service line charge amounts reported in the Institutional Service Line (SV2) segments for this claim. 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”). CLM-05 C023 Health Care Service Location Information To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered Max use 1 Required C023-01 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. C023-02 1332 Facility Code Qualifier Identifier (ID) Required Code identifying the type of facility referenced C023-02 qualifies C023-01 and C023-03. A Uniform Billing Claim Form Bill Type C023-03 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Required Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type CLM-07 1359 Assignment or Plan Participation Code Identifier (ID) Required Code indicating whether the provider accepts assignment Usage notes Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08. A Assigned Required when the provider accepts assignment and/or has a participation agreement with the destination payer. OR 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 55/285 Required when the provider does not accept assignment and/or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans. B Assignment Accepted on Clinical Lab Services Only Required when the provider accepts assignment for Clinical Lab Services only. C Not Assigned Required when neither codes A' nor B' apply. CLM-08 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code `W' when the patient refuses to assign benefits. Y Yes CLM-09 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. CLM-20 1514 Delay Reason Code Identifier (ID) Optional Code indicating the reason why a request was delayed Usage notes Data submitted in CLM20 will not be used for processing 1 Proof of Eligibility Unknown or Unavailable 2 Litigation 3 Authorization Delays 4 Delay in Certifying Provider 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 56/285 5 Delay in Supplying Billing Forms 6 Delay in Delivery of Custom-made Appliances 7 Third Party Processing Delay 8 Delay in Eligibility Determination 9 Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules 10 Administration Delay in the Prior Approval Process 11 Other 15 Natural Disaster 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 57/285 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Admission Date/Hour To specify any or all of a date, a time, or a time period Usage notes Required on inpatient claims. If not required by this implementation guide, do not send. Example DTP435D8XXX~ Variants (all may be used) DTP Date - Repricer Received Date DTP Discharge Hour DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 435 Admission DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. Usage notes Selection of the appropriate qualifier is designated by the NUBC Billing Manual. Must not be a future date. D8 Date Expressed in Format CCYYMMDD DT Date and Time Expressed in Format CCYYMMDDHHMM DTP-03 1251 Admission Date and Hour Min 1 Max 35 String (AN) Required Expression of a date, a time, or	CGS Medicare 837 Health Care Claim_ Institutional.pdf
assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code `W' when the patient refuses to assign benefits. Y Yes CLM-09 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. CLM-20 1514 Delay Reason Code Identifier (ID) Optional Code indicating the reason why a request was delayed Usage notes Data submitted in CLM20 will not be used for processing 1 Proof of Eligibility Unknown or Unavailable 2 Litigation 3 Authorization Delays 4 Delay in Certifying Provider 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 56/285 5 Delay in Supplying Billing Forms 6 Delay in Delivery of Custom-made Appliances 7 Third Party Processing Delay 8 Delay in Eligibility Determination 9 Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules 10 Administration Delay in the Prior Approval Process 11 Other 15 Natural Disaster 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 57/285 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Admission Date/Hour To specify any or all of a date, a time, or a time period Usage notes Required on inpatient claims. If not required by this implementation guide, do not send. Example DTP435D8XXX~ Variants (all may be used) DTP Date - Repricer Received Date DTP Discharge Hour DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 435 Admission DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. Usage notes Selection of the appropriate qualifier is designated by the NUBC Billing Manual. Must not be a future date. D8 Date Expressed in Format CCYYMMDD DT Date and Time Expressed in Format CCYYMMDDHHMM DTP-03 1251 Admission Date and Hour Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times Usage notes Must be in format HHMM.MM 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 58/285 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Repricer Received Date To specify any or all of a date, a time, or a time period Usage notes Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send. Example DTP050D8XXXXXX~ Variants (all may be used) DTP Admission Date/Hour DTP Discharge Hour DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Repricer Received Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 59/285 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Discharge Hour To specify any or all of a date, a time, or a time period Usage notes Required on all final inpatient claims. If not required by this implementation guide, do not send. Example DTP096TMXXXXXX~ Variants (all may be used) DTP Admission Date/Hour DTP Date - Repricer Received Date DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 096 Discharge DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. TM Time Expressed in Format HHMM DTP-03 1251 Discharge Time Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 60/285 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Statement Dates To specify any or all of a date, a time, or a time period Example DTP434RD8XXXXX~ Variants (all may be used) DTP Admission Date/Hour DTP Date - Repricer Received Date DTP Discharge Hour Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 434 Statement DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD Use RD8 to indicate the from and through date of the statement. When the statement is for a single date of service, the from and through date are the same. DTP-03 1251 Statement From and To Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 61/285 CL1 1400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CL1 Institutional Claim Code To supply information specific to hospital claims Example CL1XXXX~ Max use 1 Required CL1-01 1315 Admission Type Code Min 1 Max 1 Identifier (ID) Required Code indicating the priority of this admission CL1-02 1314 Admission Source Code Min 1 Max 1 Identifier (ID) Optional Code indicating the source of this admission CL1-03 1352 Patient Status Code Min 1 Max 2 Identifier (ID) Required Code indicating patient status as of the "statement covers through date" 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 62/285 PWK 1550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > PWK Claim Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Only the first iteration of the PWK, at either the claim level and/or line level, will be considered in the claim adjudication. Example PWKA4BM*ACXX~ If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 04 Drugs Administered 05 Treatment Diagnosis 06 Initial Assessment 07 Functional Goals 08 Plan of Treatment 09 Progress Report 10 Continued Treatment 11 Chemical Analysis 13 Certified Test Report 15 Justification for Admission 21 Recovery Plan A3 Allergies/Sensitivities Document A4 Autopsy Report AM Ambulance Certification AS Admission Summary B2 Prescription B3 Physician Order B4 Referral Form BR Benchmark Testing Results BS Baseline 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 63/285 BT Blanket Test Results CB Chiropractic Justification CK Consent Form(s) CT Certification D2 Drug Profile Document DA Dental Models DB Durable Medical Equipment Prescription DG Diagnostic Report DJ Discharge Monitoring Report DS Discharge Summary EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record IR State School Immunization Records LA Laboratory Results M1 Medical Record Attachment MT Models NN Nursing Notes OB Operative Note OC Oxygen Content Averaging Report OD Orders and Treatments Document OE Objective Physical Examination (including vital signs) Document OX Oxygen Therapy Certification OZ Support Data for Claim P4 Pathology Report P5 Patient Medical History Document PE Parenteral or Enteral Certification PN Physical Therapy Notes PO Prosthetics or Orthotic Certification PQ Paramedical Results PY Physician's Report PZ Physical Therapy Certification RB Radiology Films RR Radiology Reports RT Report of Tests and Analysis Report RX Renewable Oxygen Content Averaging Report SG Symptoms Document V5 Death Notification XP Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. FT File Transfer Required when the actual attachment is maintained by an attachment warehouse or similar vendor. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 64/285 FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 65/285 AMT 1750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > AMT Patient Estimated Amount Due To indicate the total monetary amount Usage notes Required when the Patient Responsibility Amount is applicable to this claim. If not required by this implementation guide, do not send. Example AMTF300000000000000~ Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount F3 Patient Responsibility - Estimated AMT-02 782 Patient Responsibility Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 66/285 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Adjusted Repriced Claim Number To specify identifying information Usage notes Required when this information is deemed necessary by the repricer. The segment	CGS Medicare 837 Health Care Claim_ Institutional.pdf
Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 63/285 BT Blanket Test Results CB Chiropractic Justification CK Consent Form(s) CT Certification D2 Drug Profile Document DA Dental Models DB Durable Medical Equipment Prescription DG Diagnostic Report DJ Discharge Monitoring Report DS Discharge Summary EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record IR State School Immunization Records LA Laboratory Results M1 Medical Record Attachment MT Models NN Nursing Notes OB Operative Note OC Oxygen Content Averaging Report OD Orders and Treatments Document OE Objective Physical Examination (including vital signs) Document OX Oxygen Therapy Certification OZ Support Data for Claim P4 Pathology Report P5 Patient Medical History Document PE Parenteral or Enteral Certification PN Physical Therapy Notes PO Prosthetics or Orthotic Certification PQ Paramedical Results PY Physician's Report PZ Physical Therapy Certification RB Radiology Films RR Radiology Reports RT Report of Tests and Analysis Report RX Renewable Oxygen Content Averaging Report SG Symptoms Document V5 Death Notification XP Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. FT File Transfer Required when the actual attachment is maintained by an attachment warehouse or similar vendor. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 64/285 FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 65/285 AMT 1750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > AMT Patient Estimated Amount Due To indicate the total monetary amount Usage notes Required when the Patient Responsibility Amount is applicable to this claim. If not required by this implementation guide, do not send. Example AMTF300000000000000~ Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount F3 Patient Responsibility - Estimated AMT-02 782 Patient Responsibility Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 66/285 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Adjusted Repriced Claim Number To specify identifying information Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF9CXXXXXX~ Variants (all may be used) REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9C Adjusted Repriced Claim Reference Number REF-02 127 Adjusted Repriced Claim Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 67/285 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Auto Accident State To specify identifying information Usage notes Required when the services reported on this claim are related to an auto accident and the accident occurred in a country or location that has a state, province, or sub- country code named in code source 22. If not required by this implementation guide, do not send. Example REFLUX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification LU Location Number REF-02 127 Auto Accident State or Province 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 Usage notes Values in this field must be valid codes found in code source 22. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 68/285 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Claim Identifier For Transmission Intermediaries To specify identifying information Usage notes Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send. Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish. Example REFD9X~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Usage notes Number assigned by clearinghouse, van, etc. D9 Claim Number REF-02 127 Value Added Network 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 Usage notes 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 69/285 The value carried in this element is limited to a maximum of 20 positions. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 70/285 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Demonstration Project Identifier To specify identifying information Usage notes Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and/or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send. Example REFP4XXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification P4 Project Code REF-02 127 Demonstration Project 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 71/285 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Investigational Device Exemption Number To specify identifying information Usage notes Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims. If not required by this implementation guide, do not send. Example REFLXXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification LX Qualified Products List REF-02 127 Investigational Device Exemption Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 72/285 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Medical Record Number To specify identifying information Usage notes Required when the provider needs to identify for future inquiries, the actual medical record of the patient identified in either Loop ID-2010BA or Loop ID-2010CA for this episode of care. If not required by this implementation guide, do not send. Example REFEAXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EA Medical Record Identification Number REF-02 127 Medical Record 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 73/285 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Payer Claim Control Number To specify identifying information Usage notes Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REFF8XXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number REF-02 127 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 74/285 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Peer Review Organization (PRO) Approval Number To specify identifying information Usage notes Required when an external Peer Review Organization assigns an Approval Number to services deemed medically necessary by that organization. If not required by this implementation guide, do not send. Example REFG4X~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number	CGS Medicare 837 Health Care Claim_ Institutional.pdf
Reference Identification Qualifier 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 72/285 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Medical Record Number To specify identifying information Usage notes Required when the provider needs to identify for future inquiries, the actual medical record of the patient identified in either Loop ID-2010BA or Loop ID-2010CA for this episode of care. If not required by this implementation guide, do not send. Example REFEAXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EA Medical Record Identification Number REF-02 127 Medical Record 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 73/285 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Payer Claim Control Number To specify identifying information Usage notes Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REFF8XXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number REF-02 127 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 74/285 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Peer Review Organization (PRO) Approval Number To specify identifying information Usage notes Required when an external Peer Review Organization assigns an Approval Number to services deemed medically necessary by that organization. If not required by this implementation guide, do not send. Example REFG4X~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G4 Peer Review Organization (PRO) Approval Number REF-02 127 Peer Review Authorization 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 75/285 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Prior Authorization To specify identifying information Usage notes Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Required when an authorization number is assigned by the payer or UMO AND the services on this claim were preauthorized. If not required by this implementation guide, do not send. Example REFG1XXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Prior Authorization 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 76/285 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 77/285 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Referral Number To specify identifying information Usage notes Required when a referral number is assigned by the payer or Utilization Management Organization (UMO) AND a referral is involved. If not required by this implementation guide, do not send. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Example REF9FXXXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Referral 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 78/285 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Repriced Claim Number To specify identifying information Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. Example REF9AXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9A Repriced Claim Reference Number REF-02 127 Repriced Claim Reference 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 79/285 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Service Authorization Exception Code To specify identifying information Usage notes Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send. Example REF4NXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 4N Special Payment Reference Number REF-02 127 Service Authorization Exception 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 Usage notes Allowable values for this element are: 1 Immediate/Urgent Care 2 Services Rendered in a Retroactive Period 3 Emergency Care 4 Client has Temporary Medicaid 5 Request from County for Second Opinion to Determine if Recipient Can Work 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 80/285 6 Request for Override Pending 7 Special Handling 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 81/285 K3 1850 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > K3 File Information To transmit a fixed-format record or matrix contents Usage notes Required when ALL of the following conditions are met: A regulatory agency concludes it must use the K3 to meet an emergency legislative requirement; The administering regulatory agency or other state organization has completed each one of the following steps: contacted the X12N workgroup, requested a review of the K3 data requirement to ensure there is not an existing method within the implementation guide to meet this requirement X12N determines that there is no method to meet the requirement. If not required by this implementation guide, do not send. At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used : The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment. X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s). Example K3*X~ Max use 10 Optional K3-01 449 Fixed Format Information Min 1 Max 80 String (AN) Required Data in fixed format agreed upon by sender and receiver 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 82/285 NTE 1900 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > NTE Billing Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information	CGS Medicare 837 Health Care Claim_ Institutional.pdf
Reference Identification 4N Special Payment Reference Number REF-02 127 Service Authorization Exception 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 Usage notes Allowable values for this element are: 1 Immediate/Urgent Care 2 Services Rendered in a Retroactive Period 3 Emergency Care 4 Client has Temporary Medicaid 5 Request from County for Second Opinion to Determine if Recipient Can Work 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 80/285 6 Request for Override Pending 7 Special Handling 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 81/285 K3 1850 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > K3 File Information To transmit a fixed-format record or matrix contents Usage notes Required when ALL of the following conditions are met: A regulatory agency concludes it must use the K3 to meet an emergency legislative requirement; The administering regulatory agency or other state organization has completed each one of the following steps: contacted the X12N workgroup, requested a review of the K3 data requirement to ensure there is not an existing method within the implementation guide to meet this requirement X12N determines that there is no method to meet the requirement. If not required by this implementation guide, do not send. At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used : The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment. X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s). Example K3X~ Max use 10 Optional K3-01 449 Fixed Format Information Min 1 Max 80 String (AN) Required Data in fixed format agreed upon by sender and receiver 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 82/285 NTE 1900 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > NTE Billing Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. If not required by this implementation guide, do not send. Example NTEADDXXXXXX~ Variants (all may be used) NTE Claim Note Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ADD Additional Information NTE-02 352 Billing Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 83/285 NTE 1900 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > NTE Claim Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. OR Required when in the judgment of the provider, narrative information from the forms "Home Health Certification and Plan of Treatment" or "Medical Update and Patient Information" is needed to substantiate home health services. If not required by this implementation guide, do not send. The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.; Example NTERLHXXXXX~ Variants (all may be used) NTE Billing Note Max use 10 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ALG Allergies DCP Goals, Rehabilitation Potential, or Discharge Plans DGN Diagnosis Description DME Durable Medical Equipment (DME) and Supplies MED Medications NTR Nutritional Requirements ODT Orders for Disciplines and Treatments RHB Functional Limitations, Reason Homebound, or Both RLH Reasons Patient Leaves Home RNH Times and Reasons Patient Not at Home SET Unusual Home, Social Environment, or Both SFM Safety Measures SPT Supplementary Plan of Treatment UPI Updated Information NTE-02 352 Claim Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 84/285 CRC 2200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CRC EPSDT Referral To supply information on conditions Usage notes Required on Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim. If not required by this implementation guide, do not send. Example CRCZZYNUXXXXX~ Max use 1 Optional CRC-01 1136 Code Qualifier Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. ZZ Mutually Defined EPSDT Screening referral information. CRC-02 1073 Certification Condition Code Applies Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Usage notes The response answers the question: Was an EPSDT referral given to the patient? N No If no, then choose "NU" in CRC03 indicating no referral given. Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC05. AV Available - Not Used Patient refused referral. NU Not Used This conditioner indicator must be used when the submitter answers "N" in CRC02. S2 Under Treatment Patient is currently under treatment for referred diagnostic or corrective health problem. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 85/285 ST New Services Requested Patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals). OR Patient is scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).; CRC-04 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 86/285 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Admitting Diagnosis To supply information related to the delivery of health care Usage notes Required when claim involves an inpatient admission. If not required by this implementation guide, do not send.; Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HIBJ>XXXX~ Variants (all may be used) HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABJ International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BJ International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis C022-02 1271 Admitting Diagnosis Code Min 1 Max 30 String (AN) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 87/285 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 88/285 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Condition Information To supply information related to the delivery of health care Usage notes Required when there is a Condition Code that applies to this claim. If not required by this implementation guide, do not send. Example HIBG>XXXXXBG>XXXXXBG>XXXXXXBG>XXXBG>XXB G>XBG>XXXXBG>XXXXXBG>XXBG>XXXXXXBG>XXXX*BG>X XXXX~ Variants (all may be used) HI Admitting Diagnosis HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 89/285 Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String	CGS Medicare 837 Health Care Claim_ Institutional.pdf
Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis C022-02 1271 Admitting Diagnosis Code Min 1 Max 30 String (AN) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 87/285 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 88/285 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Condition Information To supply information related to the delivery of health care Usage notes Required when there is a Condition Code that applies to this claim. If not required by this implementation guide, do not send. Example HIBG>XXXXXBG>XXXXXBG>XXXXXXBG>XXXBG>XXB G>XBG>XXXXBG>XXXXXBG>XXBG>XXXXXXBG>XXXXBG>X XXXX~ Variants (all may be used) HI Admitting Diagnosis HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 89/285 Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 90/285 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 91/285 BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 92/285 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 93/285 Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 94/285 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Diagnosis Related Group (DRG) Information To supply information related to the delivery of health care Usage notes Required when an inpatient hospital is under DRG contract with a payer and the contract requires the provider to identify the DRG to the payer. If not required by this implementation guide, do not send. Example HI*DR>XXX~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. DR Diagnosis Related Group (DRG) C022-02 1271 Diagnosis Related Group (DRG) Code String (AN) Required Min 1 Max 30 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 95/285 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI External Cause of Injury To supply information related to the delivery of health care Usage notes Required when an external Cause of Injury is needed to describe an injury, poisoning, or adverse effect. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. In order to fully describe an injury using ICD-10-CM, it will be necessary to report a series of 3 external cause of injury	CGS Medicare 837 Health Care Claim_ Institutional.pdf
C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 94/285 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Diagnosis Related Group (DRG) Information To supply information related to the delivery of health care Usage notes Required when an inpatient hospital is under DRG contract with a payer and the contract requires the provider to identify the DRG to the payer. If not required by this implementation guide, do not send. Example HIDR>XXX~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. DR Diagnosis Related Group (DRG) C022-02 1271 Diagnosis Related Group (DRG) Code String (AN) Required Min 1 Max 30 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 95/285 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI External Cause of Injury To supply information related to the delivery of health care Usage notes Required when an external Cause of Injury is needed to describe an injury, poisoning, or adverse effect. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. In order to fully describe an injury using ICD-10-CM, it will be necessary to report a series of 3 external cause of injury codes. Example HIABN>X>>>>>>>NABN>XXXXXX>>>>>>>YBN>X>>>>>> >NBN>XXXXXX>>>>>>>UBN>X>>>>>>>WBN>XXX>>>>>> >WBN>XXXX>>>>>>>NBN>XXX>>>>>>>UBN>XXXXX>>>>>> >UABN>XXX>>>>>>>NBN>X>>>>>>>N*ABN>XXXXXX>>>>>> >U~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 96/285 the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 97/285 OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 98/285 BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 99/285 ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code 1/30/25, 11:54 AM CGS Medicare 837 Health	CGS Medicare 837 Health Care Claim_ Institutional.pdf
"U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 99/285 ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 100/285 This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 101/285 If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 102/285 The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 103/285 OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 104/285 BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes.	CGS Medicare 837 Health Care Claim_ Institutional.pdf
specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 103/285 OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 104/285 BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 105/285 ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 106/285 This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 107/285 If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 108/285 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Occurrence Information To supply information related to the delivery of health care Usage notes Required when there is a Occurrence Code that applies to this claim. If not required by this implementation guide, do not send. Example HIBH>XXXXX>D8>XXXXBH>XXXXXX>D8>XXXXXXBH>XXXX X>D8>XXXXXBH>X>D8>XXXXXXBH>XXXXXX>D8>XXBH>XX>D 8>XBH>XXXXX>D8>XXXBH>XXXXX>D8>XXXXBH>XXX>D8>XX XBH>XX>D8>XXXXXXBH>XXXXXX>D8>XBH>XXXXXX>D8>XX X~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 109/285 C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1	CGS Medicare 837 Health Care Claim_ Institutional.pdf
Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 108/285 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Occurrence Information To supply information related to the delivery of health care Usage notes Required when there is a Occurrence Code that applies to this claim. If not required by this implementation guide, do not send. Example HIBH>XXXXX>D8>XXXXBH>XXXXXX>D8>XXXXXXBH>XXXX X>D8>XXXXXBH>X>D8>XXXXXXBH>XXXXXX>D8>XXBH>XX>D 8>XBH>XXXXX>D8>XXXBH>XXXXX>D8>XXXXBH>XXX>D8>XX XBH>XX>D8>XXXXXXBH>XXXXXX>D8>XBH>XXXXXX>D8>XX X~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 109/285 C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 110/285 Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 111/285 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-06 C022 Health Care Code Information Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 112/285 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 113/285 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 114/285 Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required	CGS Medicare 837 Health Care Claim_ Institutional.pdf
837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 113/285 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 114/285 Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 115/285 BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 116/285 C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 117/285 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Occurrence Span Information To supply information related to the delivery of health care Usage notes Required when there is an Occurrence Span Code that applies to this claim. If not required by this implementation guide, do not send. Example HIBI>XXXXX>RD8>XXBI>XXXXX>RD8>XXBI>XXXX>RD8>XX XBI>XXXX>RD8>XXXXXBI>XX>RD8>XXXXXXBI>X>RD8>XX XBI>XX>RD8>XXXXBI>XXXX>RD8>XXXBI>XXX>RD8>XXXXX XBI>XX>RD8>XXXXXXBI>XXX>RD8>XXXBI>XX>RD8>XX~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 118/285 Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-03 C022 Health Care Code Information Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 119/285 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 120/285 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence	CGS Medicare 837 Health Care Claim_ Institutional.pdf
format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-03 C022 Health Care Code Information Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 119/285 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 120/285 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 121/285 Expression of a date, a time, or range of dates, times or dates and times HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 122/285 BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 123/285 C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 124/285 C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 125/285 RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and	CGS Medicare 837 Health Care Claim_ Institutional.pdf
guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 124/285 C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 125/285 RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 126/285 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Other Diagnosis Information To supply information related to the delivery of health care Usage notes Do not transmit the decimal point for ICD codes. The decimal point is implied. Required when other condition(s) coexist or develop(s) subsequently during the patient's treatment. If not required by this implementation guide, do not send. Example HIABF>XXXX>>>>>>>WBF>XXXX>>>>>>>YBF>XXX>>>>>> >WBF>XX>>>>>>>NABF>X>>>>>>>WBF>XX>>>>>>>UBF>X XX>>>>>>>NABF>XXX>>>>>>>UBF>XXXX>>>>>>>WBF>XXX XX>>>>>>>YABF>XXXXX>>>>>>>NABF>XXXX>>>>>>>W~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 127/285 BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 128/285 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 129/285 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 130/285 Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to	CGS Medicare 837 Health Care Claim_ Institutional.pdf
CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 129/285 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 130/285 Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 131/285 an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 132/285 C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 133/285 N No U Unknown W Not Applicable Y Yes HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 134/285 Y Yes HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or	CGS Medicare 837 Health Care Claim_ Institutional.pdf
to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 134/285 Y Yes HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-10 C022 Health Care Code Information 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 135/285 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 136/285 Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 137/285 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 138/285 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Other Procedure Information To supply information related to the delivery of health care Usage notes Required on inpatient claims when additional procedures must be reported. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HIBBQ>XXXXXX>D8>XBBQ>XXX>D8>XXXXBBQ>XXX>D8>XXX XXXBQ>XXXXX>D8>XXXXBQ>XXXXX>D8>XXXXBQ>XXXXXX>D 8>XXXXXXBBQ>XXXX>D8>XXXBQ>XX>D8>XXXBBQ>XXXX>D 8>XXXXBBQ>XX>D8>XXXXXBBQ>XXXXX>D8>XXXXXBBQ>XX X>D8>XXX~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 139/285 OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required	CGS Medicare 837 Health Care Claim_ Institutional.pdf
it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 138/285 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Other Procedure Information To supply information related to the delivery of health care Usage notes Required on inpatient claims when additional procedures must be reported. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HIBBQ>XXXXXX>D8>XBBQ>XXX>D8>XXXXBBQ>XXX>D8>XXX XXXBQ>XXXXX>D8>XXXXBQ>XXXXX>D8>XXXXBQ>XXXXXX>D 8>XXXXXXBBQ>XXXX>D8>XXXBQ>XX>D8>XXXBBQ>XXXX>D 8>XXXXBBQ>XX>D8>XXXXXBBQ>XXXXX>D8>XXXXXBBQ>XX X>D8>XXX~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 139/285 OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 140/285 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 141/285 Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 142/285 Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 143/285 Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 144/285 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants	CGS Medicare 837 Health Care Claim_ Institutional.pdf
C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 143/285 Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 144/285 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 145/285 OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 146/285 C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 147/285 Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 148/285 Expression of a date, a time, or range of dates, times or dates and times HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or	CGS Medicare 837 Health Care Claim_ Institutional.pdf
HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 148/285 Expression of a date, a time, or range of dates, times or dates and times HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 149/285 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Patient's Reason For Visit To supply information related to the delivery of health care Usage notes Required when claim involves outpatient visits. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HIPR>XXXXXAPR>XXXAPR>XX~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 150/285 APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional Patient's Reason for Visit must be sent and the preceding HI data elements have been used to report other patient's reason for visit. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 151/285 HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional Patient's Reason for Visit must be sent and the preceding HI data elements have been used to report other patient's reason for visit. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 152/285 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Principal Diagnosis To supply information related to the delivery of health care Usage notes Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HIBK>XXXXX>>>>>>>N~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Required HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABK International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BK International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis C022-02 1271 Principal Diagnosis Code Min 1 Max 30 String (AN) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 153/285 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 154/285 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Principal Procedure Information To supply information related to the delivery of health care Usage notes Required on inpatient claims when a procedure was performed. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI*CAH>XXXX>D8>XXXX~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 155/285 BBR International Classification of Diseases Clinical Modification (ICD-10-PCS) Principal Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BR International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Procedure Codes CAH Advanced Billing Concepts (ABC) Codes C022-02 1271 Principal Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents	CGS Medicare 837 Health Care Claim_ Institutional.pdf
BK International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis C022-02 1271 Principal Diagnosis Code Min 1 Max 30 String (AN) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 153/285 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 154/285 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Principal Procedure Information To supply information related to the delivery of health care Usage notes Required on inpatient claims when a procedure was performed. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HICAH>XXXX>D8>XXXX~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 155/285 BBR International Classification of Diseases Clinical Modification (ICD-10-PCS) Principal Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BR International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Procedure Codes CAH Advanced Billing Concepts (ABC) Codes C022-02 1271 Principal Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Principal Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 156/285 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Treatment Code Information To supply information related to the delivery of health care Usage notes Required when Home Health Agencies need to report Plan of Treatment information under various payer contracts. If not required by this implementation guide, do not send. Example HITC>XTC>XTC>XXTC>XXTC>XXTC>XXTC>XTC>XXXX XTC>XTC>XXXXXTC>XX*TC>XX~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 157/285 Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 158/285 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 159/285 TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 160/285 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 161/285 Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not	CGS Medicare 837 Health Care Claim_ Institutional.pdf
Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 160/285 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 161/285 Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 162/285 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Value Information To supply information related to the delivery of health care Usage notes Required when there is a Value Code that applies to this claim. If not required by this implementation guide, do not send. Example HIBE>XXX>>>0000000000BE>XX>>>0000BE>XXXXXX>>>0 00000000000000BE>XXXXX>>>000BE>XX>>>00000000000 000BE>XXXX>>>0BE>XXXXX>>>000000000000BE>XXXX>> >000000BE>XXXXX>>>000000BE>XXX>>>0000BE>X>>>00 000BE>XX>>>00000~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 163/285 C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 164/285 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 165/285 C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 166/285 BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 167/285 Code identifying a specific industry code list C022-01 qualifies C022-02,	CGS Medicare 837 Health Care Claim_ Institutional.pdf
health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 166/285 BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 167/285 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 168/285 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 169/285 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 170/285 HCP 2410 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HCP Claim Pricing/Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Example HCP1100000000000000000000000000000XXXXX00000 0000XX0XXX**UN00T45*1~ If either Unit or Basis for Measurement Code (HCP-11) or Repriced Approved Service Unit Count (HCP-12) is present, then the other is required Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 00 Zero Pricing (Not Covered Under Contract) 01 Priced as Billed at 100% 02 Priced at the Standard Fee Schedule 03 Priced at a Contractual Percentage 04 Bundled Pricing 05 Peer Review Pricing 06 Per Diem Pricing 07 Flat Rate Pricing 08 Combination Pricing 09 Maternity Pricing 10 Other Pricing 11 Lower of Cost 12 Ratio of Cost 13 Cost Reimbursed 14 Adjustment Pricing HCP-02 782 Repriced Allowed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 171/285 HCP02 is the allowed amount. HCP-03 782 Repriced Saving Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP03 is the savings amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-04 127 Repricing Organization 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 HCP04 is the repricing organization identification number. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-05 118 Repricing Per Diem or Flat Rate Amount Decimal number (R) Optional Min 1 Max 9 Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-06 127 Repriced Approved DRG 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 HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-07 782 Repriced Approved Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP07 is the approved DRG amount. Usage notes 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 172/285 This information is specific to the destination payer reported in Loop ID-2010BB. HCP-08 234 Repriced Approved Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service HCP08 is the approved revenue code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-11 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit HCP-12 380 Repriced Approved Service Unit Count Decimal number (R) Optional Min 1 Max 15 Numeric value of quantity HCP12 is the approved service units or inpatient days. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. HCP-13 901 Reject Reason Code Identifier (ID) Optional Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance Usage notes 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 173/285 This information is specific to the destination payer reported in Loop ID-2010BB. 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 174/285 2310A Attending Provider Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Attending Provider Name Loop > NM1 Attending Provider Name To supply the full name of an individual or organizational entity Usage notes Required	CGS Medicare 837 Health Care Claim_ Institutional.pdf
DRG amount. Usage notes 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 172/285 This information is specific to the destination payer reported in Loop ID-2010BB. HCP-08 234 Repriced Approved Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service HCP08 is the approved revenue code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-11 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit HCP-12 380 Repriced Approved Service Unit Count Decimal number (R) Optional Min 1 Max 15 Numeric value of quantity HCP12 is the approved service units or inpatient days. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. HCP-13 901 Reject Reason Code Identifier (ID) Optional Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance Usage notes 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 173/285 This information is specific to the destination payer reported in Loop ID-2010BB. 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 174/285 2310A Attending Provider Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Attending Provider Name Loop > NM1 Attending Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the claim contains any services other than non-scheduled transportation claims. If not required by this implementation guide, do not send. The Attending Provider is the individual who has overall responsibility for the patient's medical care and treatment reported in this claim. Example NM1711XXXXXXXXXXXXXXXXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Attending Provider Primary 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 71 Attending Physician When used, the term physician is any type of provider filling this role. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Attending Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Attending Provider First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 175/285 Individual first name NM1-05 1037 Attending Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Attending Provider 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) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Attending Provider Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 176/285 PRV 2550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Attending Provider Name Loop > PRV Attending Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when adjudication of the destination payer, or any subsequent payer listed on this claim, is known to be impacted by the attending provider taxonomy code. If not required by this implementation guide, do not send. Example PRVATPXCXXXX~ Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider AT Attending PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 177/285 2310A Attending Provider Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Attending Provider Name Loop > REF Attending Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF1GXX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Attending 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 178/285 2310B Operating Physician Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Operating Physician Name Loop > NM1 Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when a surgical procedure code is listed on this claim. If not required by this implementation guide, do not send. The Operating Physician is the individual with primary responsibility for performing the surgical procedure(s). Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1721XXXXXXXXXXXXXXXXXXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Operating Physician Primary 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 72 Operating Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Operating Physician Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Operating Physician First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 179/285 Individual first name NM1-05 1037 Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Operating Physician 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) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Operating Physician Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 180/285 2310B Operating Physician Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Operating Physician Name Loop > REF Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF1GXXXXX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Operating Physician 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 181/285 2310C Other Operating Physician Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Operating Physician Name Loop > NM1 Other Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when another Operating Physician is involved. If not required by the implementation guide, do not send. The Other Operating Physician is the individual performing a secondary surgical procedure or assisting the Operating Physician. This Other Operating Physician segment can only be used when Operating Physician information (Loop ID-2310B) is also sent on this claim. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1ZZ1XXXXXXXXXXX*XXXX*XXXXXX~ If either Identification Code Qualifier (NM1-08) or Other Operating Physician 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 ZZ Mutually Defined ZZ is used to indicate Other Operating Physician. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1	CGS Medicare 837 Health Care Claim_ Institutional.pdf
67 Operating Physician Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 180/285 2310B Operating Physician Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Operating Physician Name Loop > REF Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF1GXXXXX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Operating Physician 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 181/285 2310C Other Operating Physician Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Operating Physician Name Loop > NM1 Other Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when another Operating Physician is involved. If not required by the implementation guide, do not send. The Other Operating Physician is the individual performing a secondary surgical procedure or assisting the Operating Physician. This Other Operating Physician segment can only be used when Operating Physician information (Loop ID-2310B) is also sent on this claim. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1ZZ1XXXXXXXXXXXXXXXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Other Operating Physician 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 ZZ Mutually Defined ZZ is used to indicate Other Operating Physician. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Other Operating Physician Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 182/285 Individual last name or organizational name NM1-04 1036 Other Operating Physician First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Other Operating Physician 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) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Other Operating Physician Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 183/285 2310C Other Operating Physician Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Operating Physician Name Loop > REF Other Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REFG2XX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Other 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 184/285 2310D Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the Rendering Provider is different than the Attending Provider reported in Loop ID-2310A of this claim. AND When state or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.) If not required by this implementation guide, do not send. The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1821XXXXXXXXXX*XXXXXXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Rendering Provider 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 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Rendering Provider Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 185/285 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 Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). 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) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 186/285 2310D Rendering Provider Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Rendering Provider Name Loop > REF Rendering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REFLUXXXXXX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 187/285 2310E Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > NM1 Service Facility Location Name To supply the full name of an individual or organizational entity Usage notes Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider). If not required by this implementation guide, do not send. When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider. Example NM1772XXXX****XXXXXX~ If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary 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 77 Service Location 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 Laboratory or Facility Name Min 1 Max 60 String (AN) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 188/285 Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Laboratory or Facility Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 189/285 N3 2650 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N3 Service Facility Location Address To specify the location of the named party Usage notes If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3XXXXXXXX~ Max use 1 Required N3-01 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Laboratory or Facility Address Line Min	CGS Medicare 837 Health Care Claim_ Institutional.pdf
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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 187/285 2310E Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > NM1 Service Facility Location Name To supply the full name of an individual or organizational entity Usage notes Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider). If not required by this implementation guide, do not send. When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider. Example NM1772XXXX***XXXXXX~ If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary 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 77 Service Location 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 Laboratory or Facility Name Min 1 Max 60 String (AN) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 188/285 Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Laboratory or Facility Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 189/285 N3 2650 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N3 Service Facility Location Address To specify the location of the named party Usage notes If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3XXXXXXXX~ Max use 1 Required N3-01 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 190/285 N4 2700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > N4 Service Facility Location City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXX~ Only one of Laboratory or Facility State or Province 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 Laboratory or Facility 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 Laboratory or Facility State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Laboratory or Facility Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 191/285 Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 192/285 2310E Service Facility Location Name Loop end REF 2710 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Facility Location Name Loop > REF Service Facility Location Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send. Example REFLUXXX~ Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Laboratory or Facility 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 193/285 2310F Referring Provider Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop NM1 2500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Referring Provider Name Loop > NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes Required on an outpatient claim when the Referring Provider is different than the Attending Provider. If not required by this implementation guide, do not send. The Referring Provider is provider who sends the patient to another provider for services. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1DN1XXXXXXXXXXXXXXXXXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Referring Provider 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 DN Referring Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 194/285 2310F Referring Provider Name Loop end Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Referring Provider 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) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 195/285 2320 Other Subscriber Information Loop Max 10 Optional SBR 2900 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > SBR Other Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Usage notes Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send. All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.; See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example SBRF18XXXXXXXXXXX****14~ Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. The SBR must contain a different value in each iteration of the SBR01. Each value may only be used one time per claim. A Payer Responsibility Four B Payer Responsibility Five C Payer Responsibility Six D Payer Responsibility Seven E Payer Responsibility Eight F Payer Responsibility Nine G Payer Responsibility Ten H Payer Responsibility Eleven P Primary S Secondary T Tertiary U Unknown This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer. SBR-02 1069 Individual Relationship Code Identifier (ID) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 196/285 Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. 01 Spouse 18 Self 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship SBR-03 127 Insured Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320. SBR-04 93 Other Insured Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required Code identifying type of claim 11 Other Non-Federal Programs 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance 16 Health Maintenance Organization (HMO) Medicare Risk 17 Dental Maintenance Organization AM Automobile Medical BL Blue Cross/Blue Shield CH Champus CI Commercial Insurance Co. DS Disability FI Federal Employees Program HM Health Maintenance Organization LM Liability Medical MC Medicaid OF Other Federal Program 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 197/285 Use code OF when submitting Medicare Part D claims. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 198/285 CAS 2950 Detail > Billing Provider Hierarchical Level	CGS Medicare 837 Health Care Claim_ Institutional.pdf
payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.; See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example SBRF18XXXXXXXXXXX****14~ Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. The SBR must contain a different value in each iteration of the SBR01. Each value may only be used one time per claim. A Payer Responsibility Four B Payer Responsibility Five C Payer Responsibility Six D Payer Responsibility Seven E Payer Responsibility Eight F Payer Responsibility Nine G Payer Responsibility Ten H Payer Responsibility Eleven P Primary S Secondary T Tertiary U Unknown This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer. SBR-02 1069 Individual Relationship Code Identifier (ID) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 196/285 Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. 01 Spouse 18 Self 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship SBR-03 127 Insured Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320. SBR-04 93 Other Insured Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required Code identifying type of claim 11 Other Non-Federal Programs 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance 16 Health Maintenance Organization (HMO) Medicare Risk 17 Dental Maintenance Organization AM Automobile Medical BL Blue Cross/Blue Shield CH Champus CI Commercial Insurance Co. DS Disability FI Federal Employees Program HM Health Maintenance Organization LM Liability Medical MC Medicaid OF Other Federal Program 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 197/285 Use code OF when submitting Medicare Part D claims. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 198/285 CAS 2950 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > CAS Claim Level Adjustments 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 Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send. Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged. Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment. Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.; 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 particular Claim Adjustment Group Code (CAS01). The first non-zero 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). CAS segment must not be present when 2000B SBR01 = “P” Example CASCRXXX000000000000000000000000000000XXX X00000000000XXXX00000000000000XXX00000X X00000000000000000XXXXX0000000000000000~ 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 Max use 5 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 199/285 If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals OA Other adjustments PI Payor Initiated Reductions 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 See 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. 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. 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 200/285 CAS06 is the amount of the adjustment. 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. 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. 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. 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 Monetary amount CAS12 is the amount of the adjustment. 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. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 201/285 CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. 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. 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. 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. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 202/285 AMT 3000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT Coordination of Benefits (COB) Payer Paid Amount To indicate the total monetary amount Usage notes Required when the claim has been adjudicated by the payer identified in Loop ID- 2330B of this loop. OR Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency. If not required by this implementation guide, do not send.; Example AMTD0000000~ Variants (all may be used) AMT Coordination of Benefits (COB) Total Non-Covered Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount Usage notes Medicare requires that one occurrence of 2320 loop with an AMT segment where AMT01 = “D” must be present when 2000B SBR01 = “S”. D Payor Amount Paid AMT-02 782 Payer Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes It is acceptable to show "0" as the amount paid. When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 203/285 AMT 3000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT Coordination of Benefits (COB) Total Non-Covered Amount To indicate the total monetary amount Usage notes Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send. When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer. Example AMTA8000000000~ Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount A8 Noncovered Charges - Actual AMT-02 782 Non-Covered Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 204/285 AMT 3000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT Remaining Patient Liability To indicate the total monetary amount Usage notes Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only. OR Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information. If not required by this implementation guide, do not send. In the	CGS Medicare 837 Health Care Claim_ Institutional.pdf
Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT Coordination of Benefits (COB) Payer Paid Amount To indicate the total monetary amount Usage notes Required when the claim has been adjudicated by the payer identified in Loop ID- 2330B of this loop. OR Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency. If not required by this implementation guide, do not send.; Example AMTD0000000~ Variants (all may be used) AMT Coordination of Benefits (COB) Total Non-Covered Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount Usage notes Medicare requires that one occurrence of 2320 loop with an AMT segment where AMT01 = “D” must be present when 2000B SBR01 = “S”. D Payor Amount Paid AMT-02 782 Payer Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes It is acceptable to show "0" as the amount paid. When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 203/285 AMT 3000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT Coordination of Benefits (COB) Total Non-Covered Amount To indicate the total monetary amount Usage notes Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send. When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer. Example AMTA8000000000~ Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount A8 Noncovered Charges - Actual AMT-02 782 Non-Covered Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 204/285 AMT 3000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > AMT Remaining Patient Liability To indicate the total monetary amount Usage notes Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only. OR Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information. If not required by this implementation guide, do not send. In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMTEAF00000000000000~ Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Coordination of Benefits (COB) Total Non-Covered Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 205/285 OI 3100 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > OI Other Insurance Coverage Information To specify information associated with other health insurance coverage Usage notes All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320. Example OI*NY~ Max use 1 Required OI-03 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response OI03 is the assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This is a crosswalk from CLM08 when doing COB. This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code `W' when the patient refuses to assign benefits. Y Yes OI-06 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes This is a crosswalk from CLM09 when doing COB. The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 206/285 MIA 3150 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > MIA Inpatient Adjudication Information To provide claim-level data related to the adjudication of Medicare inpatient claims Usage notes Required when inpatient adjudication information is reported in the remittance advice. OR Required when it is necessary to report remark codes. If not required by this implementation guide, do not send. Example MIA000000000*00000000000000000000000000XXX00 000000000000000000000000000000000000000000000 0000000000000000000000000000000000000000000 0000000000000000000000000000000000000XXXXXX XXXXXX000000000000~ 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. 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 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 Decimal number (R) Optional Min 1 Max 15 Monetary amount 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 207/285 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 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 208/285 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 Non-Payable Professional Component Billed 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 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 209/285 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. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 210/285 MOA 3200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber 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 outpatient adjudication information is reported in the remittance advice OR Required when it is necessary to report remark codes. If not required by this implementation guide, do not send. Example MOA00000000XXXXXXXXXXXXXXXXXX000000000000 00*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 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. 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 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier	CGS Medicare 837 Health Care Claim_ Institutional.pdf
Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Non-Payable Professional Component Billed 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 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 209/285 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. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 210/285 MOA 3200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber 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 outpatient adjudication information is reported in the remittance advice OR Required when it is necessary to report remark codes. If not required by this implementation guide, do not send. Example MOA00000000XXXXXXXXXXXXXXXXXX000000000000 000000000~ 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 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. 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 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 211/285 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 End Stage Renal Disease Payment Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Non-Payable Professional Component Billed Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 212/285 2330A Other Subscriber Name Loop Max 1 Required Variants (all may be used) Other Payer Name Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.; If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1IL1XXXXXXXX*XXXXXMIXXXXX~ 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 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 Other Insured Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Other Insured First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 213/285 Individual first name NM1-05 1037 Other Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Other Insured 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) II Standard Unique Health Identifier for each Individual in the United States Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead. MI Member Identification Number The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.) MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Other Insured Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 214/285 N3 3320 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N3 Other Subscriber Address To specify the location of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N3XXXXXXXX~ Max use 1 Optional N3-01 166 Other Insured Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Insured Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 215/285 N4 3400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > N4 Other Subscriber City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N4XXXXXXXXXXXXXX~ Only one of Other Insured 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 Other Insured 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 Other Insured 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 Other Insured 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 216/285 Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 217/285 2330A Other Subscriber Name Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > REF Other Subscriber Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. Example REFSYXXXXX~ Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Other Insured Additional Identifier Min 1 Max 9 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes 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. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 218/285 2330B Other Payer Name Loop Max 1 Required Variants (all may be used) Other Subscriber Name Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > NM1 Other Payer Name To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1PR2XX****XVXXXXX~ 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 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 Other Payer Last or Organization 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) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the	CGS Medicare 837 Health Care Claim_ Institutional.pdf
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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 216/285 Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 217/285 2330A Other Subscriber Name Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Subscriber Name Loop > REF Other Subscriber Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. Example REFSYXXXXX~ Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Other Insured Additional Identifier Min 1 Max 9 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes 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. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 218/285 2330B Other Payer Name Loop Max 1 Required Variants (all may be used) Other Subscriber Name Loop NM1 3250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > NM1 Other Payer Name To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1PR2XX***XVXXXXX~ 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 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 Other Payer Last or Organization 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) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 219/285 segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.; 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 220/285 N3 3320 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N3 Other Payer Address To specify the location of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N3XXXXXXX~ Max use 1 Optional N3-01 166 Other Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 221/285 N4 3400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > N4 Other Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N4XXXXXXXXXXXXXX~ Only one of Other 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 Optional N4-01 19 Other 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 Other 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 Other 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. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 222/285 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 223/285 DTP 3500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > DTP Claim Check or Remittance Date To specify any or all of a date, a time, or a time period Usage notes Required when the payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If not required by this implementation guide, do not send.; Example DTP573D8XXXXXX~ Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times Usage notes Must not be future date. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 224/285 REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Claim Adjustment Indicator To specify identifying information Usage notes Required when the claim is being sent in the payer-to-payer COB model, AND the destination payer is secondary to the payer identified in this Loop ID-2330B, AND the payer identified in this Loop ID-2330B has re-adjudicated the claim. If not required by this implementation guide, do not send. Example REFT4XXXXX~ Variants (all may be used) REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification T4 Signal Code REF-02 127 Other Payer Claim Adjustment Indicator 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 Only allowed value is "Y". 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 225/285 REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Claim Control Number To specify identifying information Usage notes Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation. OR Required when the Other Payer's Claim Control Number is available. If not required by this implementation guide, do not send. Example REFF8X~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number This is the payer's internal Claim Control Number for this claim for the payer identified in this iteration of Loop ID-2330. This value is typically used in payer-to-payer COB situations only. REF-02 127 Other Payer's 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 226/285 REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Prior Authorization Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a prior authorization number to this claim. If not required by this implementation guide, do not send. Example REFG1XXXX~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Other Payer Prior Authorization 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 227/285 REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Referral Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a referral number to this claim. If not required by this implementation guide, do not send. Example REF9F*XXXX~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Other Payer Prior Authorization or Referral Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional	CGS Medicare 837 Health Care Claim_ Institutional.pdf
Loop > Other Payer Name Loop > REF Other Payer Claim Control Number To specify identifying information Usage notes Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation. OR Required when the Other Payer's Claim Control Number is available. If not required by this implementation guide, do not send. Example REFF8X~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number This is the payer's internal Claim Control Number for this claim for the payer identified in this iteration of Loop ID-2330. This value is typically used in payer-to-payer COB situations only. REF-02 127 Other Payer's 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 226/285 REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Prior Authorization Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a prior authorization number to this claim. If not required by this implementation guide, do not send. Example REFG1XXXX~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Other Payer Prior Authorization 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 227/285 REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Referral Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a referral number to this claim. If not required by this implementation guide, do not send. Example REF9FXXXX~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Other Payer Prior Authorization or Referral Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 228/285 2330B Other Payer Name Loop end 2320 Other Subscriber Information Loop end REF 3550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Other Subscriber Information Loop > Other Payer Name Loop > REF Other Payer Secondary Identifier To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REFFYXXX~ Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Other Payer 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 229/285 2400 Service Line Number Loop Max 999 Required LX 3650 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > LX Service Line Number To reference a line number in a transaction set Usage notes The LX functions as a line counter. The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim. LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on bundling and unbundling. 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 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). 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 230/285 SV2 3750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > SV2 Institutional Service Line To specify the service line item detail for a health care institution Example SV2XXXXHC>X>XX>XX>XX>XX>XXXXXX0000UN0*00000 0~ Max use 1 Required SV2-01 234 Service Line Revenue Code Min 1 Max 48 String (AN) Required Identifying number for a product or service SV201 is the revenue code. Usage notes See Code Source 132: National Uniform Billing Committee (NUBC) Codes. SV2-02 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers Usage notes Required for outpatient claims when an appropriate procedure code exists for this service line item. OR Required for inpatient claims when an appropriate HCPCS (drugs and/or biologics only) or HIPPS code exists for this service line item. 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. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code 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. Usage notes 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, 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 231/285 A0488, or A0436 (nonscheduled transportation claim) are the only codes present, 2310A NM1 must not be preset. Otherwise, 2310A NM1 must be present. 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 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. SV2-03 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SV203 is the submitted service line item amount. Usage notes This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax amounts reported within this line's AMT segments. Zero "0" is an acceptable value for this element. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 232/285 SV203 must be greater than zero. SV203’s decimal positions are limited to 0, 1, or 2. SV2-04 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit SV2-05 380 Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SV205 must be greater than zero and less than or equal to “999,999.9”. Must be 0 or 1 decimal position. SV2-07 782 Line Item Denied Charge or Non-Covered Charge Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount SV207 is a non-covered service amount. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 233/285 PWK 4200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PWK Line Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWK10FX*ACXXXXXXX~ If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 04 Drugs Administered 05 Treatment Diagnosis 06 Initial Assessment 07 Functional Goals 08 Plan of Treatment 09 Progress Report 10 Continued Treatment 11 Chemical Analysis 13 Certified Test Report 15 Justification for Admission 21 Recovery Plan A3 Allergies/Sensitivities Document A4 Autopsy Report AM Ambulance Certification AS Admission Summary B2 Prescription B3 Physician Order B4 Referral Form BR Benchmark Testing Results BS Baseline BT Blanket Test Results CB Chiropractic Justification 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 234/285 CK Consent Form(s) CT Certification D2 Drug Profile Document DA Dental Models DB Durable Medical Equipment Prescription DG Diagnostic Report DJ Discharge Monitoring Report DS Discharge Summary EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record IR State School Immunization Records LA Laboratory Results M1 Medical Record Attachment MT Models NN	CGS Medicare 837 Health Care Claim_ Institutional.pdf
for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit SV2-05 380 Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SV205 must be greater than zero and less than or equal to “999,999.9”. Must be 0 or 1 decimal position. SV2-07 782 Line Item Denied Charge or Non-Covered Charge Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount SV207 is a non-covered service amount. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 233/285 PWK 4200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > PWK Line Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWK10FX**ACXXXXXXX~ If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 04 Drugs Administered 05 Treatment Diagnosis 06 Initial Assessment 07 Functional Goals 08 Plan of Treatment 09 Progress Report 10 Continued Treatment 11 Chemical Analysis 13 Certified Test Report 15 Justification for Admission 21 Recovery Plan A3 Allergies/Sensitivities Document A4 Autopsy Report AM Ambulance Certification AS Admission Summary B2 Prescription B3 Physician Order B4 Referral Form BR Benchmark Testing Results BS Baseline BT Blanket Test Results CB Chiropractic Justification 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 234/285 CK Consent Form(s) CT Certification D2 Drug Profile Document DA Dental Models DB Durable Medical Equipment Prescription DG Diagnostic Report DJ Discharge Monitoring Report DS Discharge Summary EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record IR State School Immunization Records LA Laboratory Results M1 Medical Record Attachment MT Models NN Nursing Notes OB Operative Note OC Oxygen Content Averaging Report OD Orders and Treatments Document OE Objective Physical Examination (including vital signs) Document OX Oxygen Therapy Certification OZ Support Data for Claim P4 Pathology Report P5 Patient Medical History Document PE Parenteral or Enteral Certification PN Physical Therapy Notes PO Prosthetics or Orthotic Certification PQ Paramedical Results PY Physician's Report PZ Physical Therapy Certification RB Radiology Films RR Radiology Reports RT Report of Tests and Analysis Report RX Renewable Oxygen Content Averaging Report SG Symptoms Document V5 Death Notification XP Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent AA Available on Request at Provider Site This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 235/285 Required when the actual attachment is maintained by an attachment warehouse or similar vendor. FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 236/285 DTP 4550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > DTP Date - Service Date To specify any or all of a date, a time, or a time period Usage notes Required on outpatient service lines where a drug is not being billed and the Statement Covers Period is greater than one day. OR Required on service lines where a drug is being billed and the payer's adjudication is known to be impacted by the drug duration or the date the prescription was written. If not required by this implementation guide, do not send. In cases where a drug is being billed on a service line, date range may be used to indicate drug duration for which the drug supply will be used by the patient. The difference in dates, including both the begin and end dates, are the days supply of the drug. Example: 20000101 - 20000107 (1/1/00 to 1/7/00) is used for a 7 day supply where the first day of the drug used by the patient is 1/1/00. In the event a drug is administered on less than a daily basis (for example, every other day) the date range would include the entire period during which the drug was supplied, including the last day the drug was used. Example: 20000101 - 20000108 (1/1/00 to 1/8/00) is used for an 8 days supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on 1/1/00. In cases where a drug is being billed on a service line, a single date may be used to indicate the date the prescription was written (or otherwise communicated by the prescriber if not written). Example DTP472D8XX~ Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 472 Service DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. Usage notes RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same. D8 Date Expressed in Format CCYYMMDD RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD DTP-03 1251 Service Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 237/285 Usage notes Must not be a future date, except for type of bill 0322 after 1/1/2021 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 238/285 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Adjusted Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF9DXXX~ Variants (all may be used) REF Line Item Control Number REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9D Adjusted Repriced Line Item Reference Number REF-02 127 Adjusted Repriced Line Item Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 239/285 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Line Item Control Number To specify identifying information Usage notes Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send. The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred. Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line. Example REF6RXXXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Repriced Line Item Reference Number 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 Usage notes The maximum number of characters to be supported for this field is 30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any receiving system is 30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 240/285 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF9B*XXXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Line Item Control Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9B Repriced Line Item Reference Number REF-02 127 Repriced Line Item Reference 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 241/285 AMT 4750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT Facility Tax Amount To indicate the total monetary amount Usage notes Required when a facility tax or surcharge applies to the service being reported in SV201 and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send. When reporting the Facility Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV203) for this service line must include	CGS Medicare 837 Health Care Claim_ Institutional.pdf
from the payer. If not required by this implementation guide, do not send. The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred. Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line. Example REF6RXXXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Repriced Line Item Reference Number 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 Usage notes The maximum number of characters to be supported for this field is 30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any receiving system is 30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 240/285 REF 4700 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > REF Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF9BXXXXX~ Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Line Item Control Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9B Repriced Line Item Reference Number REF-02 127 Repriced Line Item Reference 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 241/285 AMT 4750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT Facility Tax Amount To indicate the total monetary amount Usage notes Required when a facility tax or surcharge applies to the service being reported in SV201 and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send. When reporting the Facility Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV203) for this service line must include the amount reported in the Facility Tax Amount. Example AMTN80~ Variants (all may be used) AMT Service Tax Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount N8 Miscellaneous Taxes AMT-02 782 Facility Tax Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 242/285 AMT 4750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > AMT Service Tax Amount To indicate the total monetary amount Usage notes Required when a service tax or surcharge applies to the service being reported in SV201 and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send. When reporting the Service Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV203) for this service line must include the amount reported in the Service Tax Amount. Example AMTGT000000000000000~ Variants (all may be used) AMT Facility Tax Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount GT Goods and Services Tax AMT-02 782 Service Tax Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 243/285 NTE 4850 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > NTE Third Party Organization Notes To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when the TPO/repricer needs to forward additional information to the payer. This segment is not completed by providers. If not required by this implementation guide, do not send. Example NTETPOXX~ Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies TPO Third Party Organization Notes NTE-02 352 Line Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 244/285 HCP 4920 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > HCP Line Pricing/Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Example HCP140000000000000000000000X0000000XXX00 0XXHPXXXXXXDA000000000000T64*4~ If either Product or Service ID Qualifier (HCP-09) or Repriced Approved HCPCS Code (HCP-10) is present, then the other is required If either Unit or Basis for Measurement Code (HCP-11) or Quantity (HCP-12) is present, then the other is required Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 00 Zero Pricing (Not Covered Under Contract) 01 Priced as Billed at 100% 02 Priced at the Standard Fee Schedule 03 Priced at a Contractual Percentage 04 Bundled Pricing 05 Peer Review Pricing 06 Per Diem Pricing 07 Flat Rate Pricing 08 Combination Pricing 09 Maternity Pricing 10 Other Pricing 11 Lower of Cost 12 Ratio of Cost 13 Cost Reimbursed 14 Adjustment Pricing HCP-02 782 Monetary Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 245/285 HCP02 is the allowed amount. HCP-03 782 Monetary Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP03 is the savings amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-04 127 Reference Identification Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-05 118 Rate Min 1 Max 9 Decimal number (R) Optional Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-06 127 Reference Identification Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-07 782 Monetary Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP07 is the approved DRG amount. Usage notes 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 246/285 This information is specific to the destination payer reported in Loop ID-2010BB. HCP-08 234 Product or Service ID Min 1 Max 48 String (AN) Optional Identifying number for a product or service HCP08 is the approved revenue code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-09 235 Product or Service ID Qualifier Identifier (ID) Optional Code identifying the type/source of the descriptive number used in Product/Service ID (234) ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code 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: If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. HCP-10 234 Repriced Approved HCPCS Code Min 1 Max 48 String (AN) Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 247/285 Identifying number for a product or service HCP10 is the approved procedure code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-11 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit HCP-12 380 Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity HCP12 is the approved service units or inpatient days. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. HCP-13 901 Reject Reason Code Identifier (ID) Optional Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying	CGS Medicare 837 Health Care Claim_ Institutional.pdf
be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code 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: If a new rule names the Home Infusion EDI Coalition (HIEC) Product/Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. HCP-10 234 Repriced Approved HCPCS Code Min 1 Max 48 String (AN) Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 247/285 Identifying number for a product or service HCP10 is the approved procedure code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-11 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit HCP-12 380 Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity HCP12 is the approved service units or inpatient days. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. HCP-13 901 Reject Reason Code Identifier (ID) Optional Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 248/285 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 249/285 2410 Drug Identification Loop Max 1 Optional LIN 4930 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > LIN Drug Identification To specify basic item identification data Usage notes Drugs and biologics reported in this segment are a further specification of service(s) described in the SV2 segment of this Service Line Loop ID-2400. Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers. OR Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes. If not required by this implementation guide, do not send. Example LIN*N4XXXX~ Max use 1 Required LIN-02 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) LIN02 through LIN31 provide for fifteen different product/service IDs for each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or SKU. N4 National Drug Code in 5-4-2 Format LIN-03 234 National Drug Code Min 1 Max 48 String (AN) Required Identifying number for a product or service 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 250/285 CTP 4940 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > CTP Drug Quantity To specify pricing information Example CTP***000F2~ Max use 1 Required CTP-04 380 National Drug Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes 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. CTP-05 C001 Composite Unit of Measure To identify a composite unit of measure (See Figures Appendix for examples of use) Max use 1 Required C001-01 355 Code Qualifier Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken F2 International Unit GR Gram ME Milligram ML Milliliter UN Unit 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 251/285 2410 Drug Identification Loop end REF 4950 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Drug Identification Loop > REF Prescription or Compound Drug Association Number To specify identifying information Usage notes In cases where a compound drug is being billed, the components of the compound will all have the same prescription number. Payers receiving the claim can relate all the components by matching the prescription number. Required when dispensing of the drug has been done with an assigned prescription number. OR Required when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number. If not required by this implementation guide, do not send. For cases where the drug is provided without a prescription (for example, from a physician's office), the value provided in this segment is a "link sequence number". The link sequence number is a provider assigned number that is unique to this claim. Its purpose is to enable the receiver to piece together the components of the compound. Example REFVYX~ Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification VY Link Sequence Number XZ Pharmacy Prescription Number REF-02 127 Prescription 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 252/285 2420A Operating Physician Name Loop Max 1 Optional Variants (all may be used) Other Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Operating Physician Name Loop > NM1 Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when a surgical procedure code is listed on this claim. AND The Operating Physician for this line is different than the Operating Physician reported in Loop ID-2310B (claim level). If not required by this implementation guide, do not send. The Operating Physician is the individual with primary responsibility for performing the surgical procedure(s). Example NM1721XXXXXXXXXXXXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Operating Physician Primary 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 72 Operating Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Operating Physician Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Operating Physician First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 253/285 Individual first name NM1-05 1037 Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Operating Physician 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) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Operating Physician Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 254/285 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Operating Physician Name Loop > REF Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF1GXXXX*2U>XXXXXX~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Operating Physician 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 REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 255/285 2420A Operating Physician Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary 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 The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B	CGS Medicare 837 Health Care Claim_ Institutional.pdf
https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 253/285 Individual first name NM1-05 1037 Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Operating Physician 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) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Operating Physician Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 254/285 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Operating Physician Name Loop > REF Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF1GXXXX*2U>XXXXXX~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Operating Physician 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 REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 255/285 2420A Operating Physician Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary 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 The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 256/285 2420B Other Operating Physician Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Other Operating Physician Name Loop > NM1 Other Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when another Operating Physician is involved, AND The Other Operating Physician for this line is different than the Other Operating Physician reported in Loop ID-2310C (claim level). If not required by this implementation guide, do not send.; Example NM1ZZ1XXXXXX*XXXXXXXXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Other Operating Physician 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 ZZ Mutually Defined ZZ is used to indicate Other Operating Physician. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Other Operating Physician Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Other Operating Physician First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 257/285 Individual first name NM1-05 1037 Other Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Other Operating Physician 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) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Other Operating Physician Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 258/285 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Other Operating Physician Name Loop > REF Other Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF1GXXXXX2U>XXXXXX~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Other 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 REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 259/285 2420B Other Operating Physician Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary 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 The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 260/285 2420C Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Other Operating Physician Name Loop Referring Provider Name Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when Rendering Provider is different than the Attending Provider reported in the 2310A loop of this claim. AND State or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.) AND The Rendering Provider for this line is different than the Rendering Provider reported in Loop ID 2310D (claim level). If not required by this implementation guide, do not send. The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure. Example NM1821XXXXXXXXXXXXXX*XXXXX~ If either Identification Code Qualifier (NM1-08) or Rendering Provider 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 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Rendering Provider Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 261/285 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 Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). 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) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 262/285 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > REF Rendering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF0BX*2U>XXXXX~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. 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 REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 263/285 2420C Rendering Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number	CGS Medicare 837 Health Care Claim_ Institutional.pdf
NM103. 1 Person NM1-03 1035 Rendering Provider Last Name Min 1 Max 60 String (AN) Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 261/285 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 Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). 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) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 262/285 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Rendering Provider Name Loop > REF Rendering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF0BX*2U>XXXXX~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. 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 REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 263/285 2420C Rendering Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary 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 The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 264/285 2420D Referring Provider Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop NM1 5000 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Referring Provider Name Loop > NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes Required on an outpatient claim when the Referring Provider is different than the Attending Provider. AND The Referring Provider for this line is different than the Referring Provider reported in Loop ID 2310F (claim level). If not required by this implementation guide, do not send. The Referring Provider is provider who sends the patient to another provider for services. Example NM1DN1XXXXXX*XXXXXXXX~ If either Identification Code Qualifier (NM1-08) or Referring Provider 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 DN Referring Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 265/285 Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Referring Provider 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) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 266/285 REF 5250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Referring Provider Name Loop > REF Referring Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF0BXX2U>XXXXX~ Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring 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 REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 267/285 2420D Referring Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary 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 The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 268/285 2430 Line Adjudication Information Loop Max 15 Optional SVD 5400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > SVD Line Adjudication Information To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers Usage notes 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. If not required by this implementation guide, do not send. To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines. Example SVDXX00000000000000HP>XX>XX>XX>XX>XX>XXXXXXXX X0000*00~ Max use 1 Required SVD-01 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code SVD01 is the payer identification code. Usage notes This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109). SVD-02 782 Service Line Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVD02 is the amount paid for this service line. Usage notes Zero "0" is an acceptable value for this element. SVD-03 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code. Usage notes Required when a line level procedure code other than a revenue code was returned on the 835 remittance advice (SVC01). Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 269/285 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. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code 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. Usage notes Must be greater than zero. Must be less than or equal to “999,999.9”. Must be 0 or 1 decimal position. 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 270/285 C003-06 modifies the value in C003-02 and C003-08. Usage notes Must be an integer (no decimals). 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. SVD-04 234 Service Line Revenue Code Min 1 Max 48 String (AN) Required Identifying number for a product or service SVD04 is the revenue	CGS Medicare 837 Health Care Claim_ Institutional.pdf
payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109). SVD-02 782 Service Line Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVD02 is the amount paid for this service line. Usage notes Zero "0" is an acceptable value for this element. SVD-03 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code. Usage notes Required when a line level procedure code other than a revenue code was returned on the 835 remittance advice (SVC01). Max use 1 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 269/285 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. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code 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. Usage notes Must be greater than zero. Must be less than or equal to “999,999.9”. Must be 0 or 1 decimal position. 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 270/285 C003-06 modifies the value in C003-02 and C003-08. Usage notes Must be an integer (no decimals). 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. SVD-04 234 Service Line Revenue Code Min 1 Max 48 String (AN) Required Identifying number for a product or service SVD04 is the revenue code. SVD-05 380 Paid Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity SVD05 is the paid units of service. Usage notes This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SVD-06 554 Bundled Line Number Min 1 Max 6 Numeric (N0) Optional Number assigned for differentiation within a transaction set SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 271/285 CAS 5450 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > CAS Line 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 Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. 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 particular Claim Adjustment Group Code (CAS01). The first non-zero 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 CASOAX000000000000000XXXXX000000000X000 000000XX0000X0000000XX00000000~ If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required Max use 5 Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 272/285 CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals OA Other adjustments PI Payor Initiated Reductions 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 CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. 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. 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 CODE SOURCE 139: Claim Adjustment Reason Code CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. 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. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 273/285 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 CODE SOURCE 139: Claim Adjustment Reason Code CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. 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. 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 CODE SOURCE 139: Claim Adjustment Reason Code CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. 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. 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 CODE SOURCE 139: Claim Adjustment Reason Code CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 274/285 Monetary amount CAS15 is the amount of the adjustment. 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. 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 CODE SOURCE 139: Claim Adjustment Reason Code CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. 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. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 275/285 DTP 5500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > DTP Line Check or Remittance Date To specify any or all of a date, a time, or a time period Example DTP573D8X~ Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times Usage notes Must not be a future date. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 276/285 2430 Line Adjudication Information Loop end 2400 Service Line Number Loop end 2300 Claim Information Loop end 2000B Subscriber Hierarchical Level Loop end 2000A Billing Provider Hierarchical Level Loop end AMT 5505 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > AMT Remaining Patient Liability To indicate the total monetary amount Usage notes In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send. This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMTEAF00000000000000~ Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount SE 5550 Detail > SE Max use 1 Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 277/285 Detail end Transaction Set Trailer To indicate the end	CGS Medicare 837 Health Care Claim_ Institutional.pdf
(ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. 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. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 275/285 DTP 5500 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > DTP Line Check or Remittance Date To specify any or all of a date, a time, or a time period Example DTP573D8X~ Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times Usage notes Must not be a future date. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 276/285 2430 Line Adjudication Information Loop end 2400 Service Line Number Loop end 2300 Claim Information Loop end 2000B Subscriber Hierarchical Level Loop end 2000A Billing Provider Hierarchical Level Loop end AMT 5505 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > Service Line Number Loop > Line Adjudication Information Loop > AMT Remaining Patient Liability To indicate the total monetary amount Usage notes In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send. This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMTEAF00000000000000~ Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount SE 5550 Detail > SE Max use 1 Required 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 277/285 Detail end 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 SE00001~ 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 Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges. 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 278/285 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE00000000~ 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 279/285 IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA00000000000000~ 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 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 280/285 EDI Samples Example 1a: Institutional Claim ISA00* 00 ZZSENDER ZZRECEIVER 2310310142^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231031014228000000001X005010X223A3~ ST837987654005010X223A3~ BHT0019000123199609180932CH~ NM1412JONES HOSPITAL****4612345~ PERICJANE DOETE9005555555~ NM1402MEDICARE***4600120~ HL1201~ PRVBIPXC203BA0200N~ NM1852JONES HOSPITAL****XX9876540809~ N3225 MAIN STREET BARKLEY BUILDING~ N4CENTERVILLEPA17111~ REFEI567891234~ PERICCONNIETE3055551234~ HL21220~ SBRP18******MB~ NM1IL1DOEJOHNT**MI030005074A~ N3125 CITY AVENUE~ N4CENTERVILLEPA17111~ DMGD819261111M~ NM1PR2MEDICARE B****PI00435~ REFG2330127~ CLM756048Q89.93*14>A>1AYY~ DTP434RD819960911~ CL13*01~ HIBK>3669~ HIBF>4019BF>79431~ HIBH>A1>D8>19261111BH>A2>D8>19911101BH>B1>D8>19261111BH>B2>D8>19870101~ HIBE>A2>>>15.31~ HIBG>09~ NM1711JONESJOHNJ~ REF1GB99937~ SBRS01351630STATE TEACHERS**CI~ OIY*Y~ NM1IL1DOEJANES**MI222004433~ N3125 CITY AVENUE~ N4CENTERVILLEPA17111~ NM1PR2STATE TEACHERS***PI1135~ LX1~ SV20305HC>8502513.39UN1~ DTP472D819960911~ LX2~ SV20730HC>9300576.54UN3~ DTP472D819960911~ SE43987654~ GE1000000001~ IEA1000000001~ 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 281/285 Example 1b: Two Claims for the Same Provider ISA00 00 ZZSENDER ZZRECEIVER 2310310142^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231031014255000000001X005010X223A3~ ST837987654005010X223A3~ BHT0019000123200506300932CH~ NM1412JONES HOSPITAL****4612345~ PERICJANE DOETE1112223333~ NM1402TRICARE***4699999~ HL1201~ PRVBIPXC282N00000X~ NM1852JONES HOSPITAL****XX1234567890~ N3225 MAIN STREET~ N4ANYWHEREPA17111~ REFEI123456789~ HL21220~ SBRP18******CH~ NM1IL1DOEJOHNT**MI030005074~ N3125 CITY AVENUE~ N4CENTERVILLEPA17111~ DMGD819681111M~ NM1PR2TRICARE****PI99999~ CLM756048Q89.95*13>A>1CYY~ DTP434RD820050315-20050315~ CL11*01~ HIBK>3669~ HIBF>4019BF>79431~ NM1711JONESJOHNJ*XX1122334455~ REF1GU12345~ LX1~ SV20305HC>8502513.39UN1~ DTP472D820050315~ LX2~ SV20730HC>9301076.56UN3~ DTP472D820050315~ HL31220~ SBRP18******CH~ NM1IL1SMITHJOE**MI123405074~ N35 MAIN STREET~ N4ANYWHEREPA17111~ DMGD819621210M~ NM1PR2TRICARE****PI99999~ CLM756049Q50*13>A>1CYY~ DTP434RD820050401-20050401~ CL11*01~ HIBK>30000~ NM1711JONESJUDYJ*XX9999999999~ PRVATPXC363LP0200N~ LX1~ SV20300HC>8508750UN1~ DTP472D820050401~ SE48987654~ GE1000000001~ IEA1000000001~ 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 282/285 Example 1c: PPO Repriced Claim ISA00 00 ZZSENDER ZZRECEIVER 2311080220^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231108022053000000001X005010X223A3~ ST8371002005010X223A3~ BHT00190010022005072109460000CH~ NM1412REGIONAL PPO NETWORK****46123456789~ PERICSUBMITTER CONTACT INFOTE8001231234~ NM1402LOCAL INSURANCE COMPANY***4654334452~ HL1201~ NM1852GOOD HEALTH HOSPITAL***XX1257234346~ N3592 NORTH ELM STREET~ N4EDGEWOODAZ860015590~ REFEI344232321~ HL21221~ SBRP46522567AW****CI~ NM1IL1JONESJENNY**MI345U8423H~ N34512 WEST AVENUE~ N4EVANSVILLEAZ863030000~ DMGD819690731F~ NM1PR2LOCAL INSURANCE COMPANY****PI7452723~ CLM456DFH43237.5*13>A>1AYY~ DTP434RD820050706-20050706~ DTP435DT200507060800~ CL11201~ AMTF3237.5~ REF9A09459034092~ REFD904566877634343456~ HIBK>38181~ HIBF>38900~ HIBH>11>D8>20050706~ HCP03182.8854.62123456789~ NM1711JOHNSONSIMON***XX5544332211~ SBRS19T&T PLUMBING COMPANY*CI~ OIY*Y~ NM1IL1JONESGEORGE**MI56454566~ NM1PR2OTHER COVERAGE COMPANY***PI534524~ LX1~ SV20471HC>92557178UN1~ DTP472D820050706~ HCP03137.0640.94~ LX2~ SV20471HC>9256759.5UN1~ DTP472D820050706~ HCP0345.8213.68~ SE421002~ GE1000000001~ IEA1000000001~ 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 283/285 Example 1d: Out of Network Repriced Claim ISA00 00 ZZSENDER ZZRECEIVER 2310310143^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231031014349000000001X005010X223A3~ ST8371024005010X223A3~ BHT0019001024200507111335CH~ NM1412REGIONAL PPO NETWORK****46123456789~ PERICSUBMITTER CONTACT INFOTE8001231234~ NM1402CONSERVATIVE INSURANCE***46000110002~ HL1201~ NM1852LOCAL HOSPITAL***XX1122334455~ N33423 SMALL STREET~ N4COLUMBUSOH432150000~ REFEI111002222~ HL21220~ SBRP1834561W****CI~ NM1IL1SMITHJAMESA**MI34902390F~ N3934 NORTH STREET~ N4COLUMBUSOH432150000~ DMGD819621015M~ NM1PR2CONSERVATIVE INSURANCE****PI0012~ CLMW392-4914114.84*13>A>1AYY~ DTP434RD820050617-20050617~ DTP435DT200506170800~ CL11101~ AMTF314.84~ REF9A459804390823~ REFD932423466233~ HIBK>53081~ HCP000333001234******T1~ NM1711RIVERSDAWN**XX2244224455~ LX1~ SV20301HC>8227014.84UN1~ DTP472D820050617~ SE311024~ GE1000000001~ IEA1000000001~ 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 284/285 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 2a: Automobile Accident ISA00* 00 ZZSENDER ZZRECEIVER 2311080222^005010000000010T>~ GSHCSENDERGSRECEIVERGS20231108022219000000001X005010X223A3~ ST837557766005010X223A3~ BHT0019000324200511111800CH~ NM1412HALL OF FAME MEMORIAL HOSPITAL****46737373737~ PERICKATE CASEYTE7152569877~ NM1402HEISMAN INSURANCE COMPANY***46999888777~ HL1201~ PRVBIPXC203BA0200N~ NM1852HALL OF FAME MEMORIAL HOSPITAL****XX2365259638~ N31 CANTON ROAD~ N4BROKEN FIELDCA99998~ REFEI737373737~ HL21221~ SBRP******AM~ NM1IL1HOWLINGHAL**MIB999777791G~ NM1PR2HEISMAN INSURANCE COMPANY***PI999888777~ CLM67236695521545*13>A>1AYY~ DTP434RD820051031-20051101~ CL1371~ REFLUCA~ HIBK>8842~ HIPR>8842~ HIBN>E9750BN>E9860~ NM1711LOMBARDOVINCENT***XX2533698543~ LX1~ SV20450HC>98765150UN1~ DTP472D820051031~ LX2~ SV20360HC>2659175UN1~ DTP472D820051031~ LX3~ SV20312HC>86225100UN2~ DTP472D820051031~ LX4~ SV20360HC>99283220UN1~ DTP472D820051031~ SE36557766~ GE1000000001~ IEA1000000001~ 1/30/25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-institutional-x223a3/01H25JDXFJR748R6M871MGNNCJ 285/285	CGS Medicare 837 Health Care Claim_ Institutional.pdf
1 837 Companion Guide Refers to the Implementation Guides based on the HIPAA Transaction ASC X12N. Standards for Electronic Data Interchange X12N/005010x222 Health Care Claim: Professional (837P) and ASC X12N/005010x223 Health Care Claim: Institutional (837I) October 2016 2 Overview The Companion Guide provides Centene trading partners with guidelines for submitting the ASC X12N/005010x222 Health Care Claim: Professional (837P) and ASC X12N/005010x223 Health Care Claim: Institutional (837I). The Centene Companion Guide documents any assumptions, conventions, or data issues that may be specific to Centene business processes when implementing the HIPAA ASC X12N 5010A Technical Reports Type 3 (TR3). As such, this Companion Guide is unique to Centene and its affiliates. This document does NOT replace the HIPAA ASC X12N 5010A Technical Reports Type 3 (TR3) for electronic transactions, nor does it attempt to amend any of the rules therein or impose any mandates on any trading partners of Centene. This document provides information on Centene- specific code handling and situation handling that is within the parameters of the HIPAA administrative Simplification rules. Readers of this Companion Guide should be acquainted with the HIPAA Technical Reports Type 3, their structure and content. Information contained within the HIPAA TR3s has not been repeated here although the TR3s have been referenced when necessary. The HIPAA ASC X12N 5010A Technical Reports Type 3 (TR3) can be purchased at http://store.x12.org. The Companion Guide provides supplemental information to the Trading Partner Agreement (TPA) that exists between Centene and its trading partners. Refer to the TPA for guidelines pertaining to Centene legal conditions surrounding the implementations of EDI transactions and code sets. Refer to the Companion Guide for information on Centene business rules or technical requirements regarding the implementation of HIPAA compliant EDI transactions and code sets. Nothing contained in this guide is intended to amend, revoke, contradict, or otherwise alter the terms and conditions of the Trading Partner Agreement. If there is an inconsistency with the terms of this guide and the terms of the Trading Partner Agreement, the terms of the Trading Partner Agreement shall govern. Express permission to use X12 copyrighted materials within this document has been granted. Rules of Exchange The Rules of Exchange section details the responsibilities of trading partners in submitting or receiving electronic transactions with Centene. Transmission Confirmation Transmission confirmation may be received through one of two possible transactions: the ASC X12C/005010X231 Implementation Acknowledgment For Health Care Insurance (TA1, 999). A TA1 Acknowledgement is used at the ISA level of the transmission envelope structure, to confirm a positive transmission or indicate an error at the ISA level of the transmission. The 999 Acknowledgement may be used to verify a successful transmission or to indicate various types of errors. 3 Transmission Confirmation cont. Confirmations of transmissions, in the form of TA1 or 999 transactions, should be received within 24 hours of batch submissions, and usually sooner. Senders of transmissions should check for confirmations within this time frame. Batch Matching Senders of batch transmissions should note that transactions are unbundled during processing, and rebundled so that the original bundle is not replicated. Trace numbers or patient account numbers should be used for batch matching or batch balancing. TA1 Interchange Acknowledgement The TA1 Interchange Acknowledgement provides senders a positive or negative confirmation of the transmission of the ISA/IEA Interchange Control. 999 Functional Acknowledgement The 999 Functional Acknowledgement reports on all Implementation Guide edits from the Functional Group and transaction Sets. 277CA Health Care Claim Acknowledgement The X12N005010X214 Health Care Claim Acknowledgment (277CA) provides a more detailed explanation of the transaction set. Centene also provides the Pre-Adjudication rejection reason of the claim within the STC12 segment of the 2220D loop. NOTE: The STC03 – Action Code will only be a “U” if the claim failed on HIPAA validation errors, NOT Pre-Adjudication errors. Duplicate Batch Check To ensure that duplicate transmissions have not been sent, Centene checks five values within the ISA for redundancy: • ISA06, ISA08, ISA09, ISA10, ISA13 Collectively, these numbers should be unique for each transmission. A duplicate ISA/IEA receives a TA1 response of “025” (Duplicate Interchange Control Number). Duplicate Batch Check cont. To ensure that Transaction Sets (ST/SE) have not been duplicated within a transmission, Centene checks the ST02 value (Transaction Set Control Number), which should be a unique ST02 within the Functional Group transmitted. Note: ISA08 & GS03 could also be the Single Payer ID 4 New Trading Partners New trading partners should access https://www.centene.com/edifecs , register for access, and perform the steps in the Centene trading partner program. The EDI Support Desk ([email protected]) will contact you with additional steps necessary upon completing your registration. Claims Processing Acknowledgements Senders receive four types of acknowledgement transactions: the TA1 transaction to acknowledge the Interchange Control Envelope (ISA/IEA) of a transaction, the 999 transaction to acknowledge the Functional Group (GS/GE) and Transaction Set (ST/SE), the 277CA transaction to acknowledge health care claims, and the Centene Audit Report. At the claim level of a transaction, the only acknowledgement of receipt is the return of the Claim Audit Report and/or a 277CA. Coordination of Benefits (COB) Processing To ensure the proper processing of claims requiring coordination of benefits, Centene recommends that providers validate the patient’s Membership Number and supplementary or primary carrier information for every claim. Code Sets Only standard codes, valid at the time of the date(s) of service, should be used. Corrections and Reversals The 837 defines what values submitters must use to signal payers that the Inbound 837 contains a reversal or correction to a claim that has previously been submitted for processing. For both Professional and Institutional 837 claims, 2300 CLM05-3 (Claim Frequency Code) must contain a value for the National UB Data Element Specification Type List Type of Bill Position 3. Data Format/Content Centene accepts all compliant data elements on the 837 Professional Claim. The following points outline consistent data format and content issues that should be followed for submission. Dates The following statements apply to any dates within an 837 transaction: • All dates should be formatted according to Year 2000 compliance, CCYYMMDD, except for ISA segments where the date format is YYMMDD. • The only values acceptable for “CC” (century) within birthdates are 18, 19, or 20. • Dates that include hours should use the following format: CCYYMMDDHHMM. • Use Military format, or numbers from 0 to 23, to indicate hours. For example, an admission date of 201006262115 defines the date and time of June 26, 2010 at 9:1 5 PM. • No spaces or character delimiters should be used in presenting dates or times. 5 • Dates that are logically invalid (e.g. 20011301) are rejected. • Dates must be valid within the context of the transaction. For example, a patient’s birth date cannot be after the patient’s service date. Decimals All percentages should be presented in decimal format. For example, a 12.5% value should be presented as .125. Dollar amounts should be presented with decimals to indicate portions of a dollar; however, no more than two positions should follow the decimal point. Dollar amounts containing more than two positions after the decimal point are rejected. Monetary and Unit Amount Values Centene accepts all compliant data elements on the 837 Professional Claim; however, monetary or unit amount values that are in negative numbers are rejected. Delimiters Delimiters are characters used to separate data elements within a data string. Delimiters suggested for use by Centene are specified in the Interchange Header segment (the ISA level) of a transmission; these include the tilde (~) for segment separation, the asterisk () for element separation, and the colon (:) for component separation. Phone Numbers Phone numbers should be presented as contiguous number strings, without dashes or parenthesis markers. For example, the phone number (336) 555-1212 should be presented as 3365551212. Area codes should always be included. Centene requires the phone number to be AAABBBCCCC where AAA is the Area code, BBB is the telephone number prefix, and CCCC is the telephone number. Additional Items • Centene will not accept more than 97 service lines per UB-04 claim. • Centene will not accept more than 50 service lines per CMS 1500 claim. • Centene will only accept single digit diagnosis pointers in the SV107 of the 837P. • The Value Added Network Trace Number (2300-REF02) is limited to 30 characters. 6 Identification Codes and Numbers General Identifiers Federal Tax Identifiers Any Federal Tax Identifier (Employer ID or Social Security Number) used in a transmission should omit dashes or hyphens. Centene sends and receives only numeric values for all tax identifiers. Sender Identifier The Sender Identifier is presented at the Interchange Control (ISA06) of a transmission. Centene expects to see the sender’s Federal Tax Identifier (ISA05, qualifier 30) for this value. In special circumstances, Centene will accept a “Mutually Defined” (ZZ) value. Senders wishing to submit a ZZ value must confirm this identifier with Centene EDI. Payer Identifier Single Payer IDs are used for all Health Plans. Please verify directly with the Health Plan and/or Clearinghouse the Payer ID that should be used or contact the EDI Support Desk at 800 225 2573 X6075525 or [email protected]. Plan Receiver ID Payer ID All ISA08/GS03 837P/837I NMN109 when NM101 = PR Medical 68069 68069 Behavioral Health/CBH 68068 68068 Centurion 42140 42140 Provider Identifiers National Provider Identifiers (NPI) HIPAA regulation mandates that providers use their NPI for electronic claims submission. The NPI is used at the record level of HIPAA transactions; for 837 claims, it is placed in the 2010AA loop. See the 837 Professional Data Element table for specific instructions about where to place the NPI within 7 the 837 Professional file. The table also clarifies what other elements must be submitted when the NPI is used. Billing provider The Billing Provider Primary Identifier should be the group/organization ID of the billing entity, filed only at 2010AA. This will be a Type 2 (Group) NPI unless the Billing provider is a sole proprietor and processes all claims and remittances with a Type 1 (Individual) NPI. Rendering Provider When providers perform services for a subscriber/patient, the service will need to be reported in the Rendering Provider Loop (2310B or 2420A) You should only use 2420A when it is different than Loop 2310B/NM182. Referring Provider Centene has no specific requirements for Referring Provider information. Atypical Provider Atypical providers are not always assigned an NPI number, however, if an Atypical provider has been assigned an NPI, then they need to follow the same requirements as a medical provider. An Atypical provider which provides non-medical services is not required to have an NPI number (i.e. carpenters, transportation, etc). Existing Atypical providers need only send the Provider Tax ID in the REF segment of the billing provider loop. NOTE: If an NPI is billed in any part of the claim, it will not follow the Atypical Provider Logic. Subscriber Identifiers Submitters must use the entire identification code as it appears on the subscriber’s card in the 2010BA element. Claim Identifiers Centene issues a claim identification number upon receipt of any submitted claim. The ASC X12 Technical Reports (Type 3) may refer to this number as the Internal Control Number (ICN), Document Control Number (DCN), or the Claim Control Number (CCN). It is provided to senders in the Claim Audit Report and in the CLP segment of an 835 transaction. Centene returns the submitter’s Patient Account Number (2300, CLM01) on the Claims Audit Report and the 835 Claim Payment/Advice (CLP01). 8 Connectivity Media for Batch Transactions Secure File Transfer Centene encourages trading partners to consider a secure File Transfer Protocol (FTP) transmission option. Centene offers two options for connectivity via FTP. • Method A – the trading partner will push transactions to the Centene FTP server and Centene will push outbound transactions to the Centene FTP server. • Method B – The Trading partner will push transactions to the Centene FTP server and Centene will push outbound transactions to the trading partner’s FTP server. Encryption Centene offers the following methods of encryption SSH/SFTP, FTPS (Auth TLS), FTP w/PGP, HTTPS (Note this method only applies with connecting to Centene’s Secure FTP. Centene does not support retrieve files automatically via HTTPS from an external source at this time.) If PGP or SSH keys are used they will shared with the trading partner. These are not required for those connecting via SFTP or HTTPS.	508_Centene_5010_837_Companion_Guide.pdf
National Provider Identifiers (NPI) HIPAA regulation mandates that providers use their NPI for electronic claims submission. The NPI is used at the record level of HIPAA transactions; for 837 claims, it is placed in the 2010AA loop. See the 837 Professional Data Element table for specific instructions about where to place the NPI within 7 the 837 Professional file. The table also clarifies what other elements must be submitted when the NPI is used. Billing provider The Billing Provider Primary Identifier should be the group/organization ID of the billing entity, filed only at 2010AA. This will be a Type 2 (Group) NPI unless the Billing provider is a sole proprietor and processes all claims and remittances with a Type 1 (Individual) NPI. Rendering Provider When providers perform services for a subscriber/patient, the service will need to be reported in the Rendering Provider Loop (2310B or 2420A) You should only use 2420A when it is different than Loop 2310B/NM1*82. Referring Provider Centene has no specific requirements for Referring Provider information. Atypical Provider Atypical providers are not always assigned an NPI number, however, if an Atypical provider has been assigned an NPI, then they need to follow the same requirements as a medical provider. An Atypical provider which provides non-medical services is not required to have an NPI number (i.e. carpenters, transportation, etc). Existing Atypical providers need only send the Provider Tax ID in the REF segment of the billing provider loop. NOTE: If an NPI is billed in any part of the claim, it will not follow the Atypical Provider Logic. Subscriber Identifiers Submitters must use the entire identification code as it appears on the subscriber’s card in the 2010BA element. Claim Identifiers Centene issues a claim identification number upon receipt of any submitted claim. The ASC X12 Technical Reports (Type 3) may refer to this number as the Internal Control Number (ICN), Document Control Number (DCN), or the Claim Control Number (CCN). It is provided to senders in the Claim Audit Report and in the CLP segment of an 835 transaction. Centene returns the submitter’s Patient Account Number (2300, CLM01) on the Claims Audit Report and the 835 Claim Payment/Advice (CLP01). 8 Connectivity Media for Batch Transactions Secure File Transfer Centene encourages trading partners to consider a secure File Transfer Protocol (FTP) transmission option. Centene offers two options for connectivity via FTP. • Method A – the trading partner will push transactions to the Centene FTP server and Centene will push outbound transactions to the Centene FTP server. • Method B – The Trading partner will push transactions to the Centene FTP server and Centene will push outbound transactions to the trading partner’s FTP server. Encryption Centene offers the following methods of encryption SSH/SFTP, FTPS (Auth TLS), FTP w/PGP, HTTPS (Note this method only applies with connecting to Centene’s Secure FTP. Centene does not support retrieve files automatically via HTTPS from an external source at this time.) If PGP or SSH keys are used they will shared with the trading partner. These are not required for those connecting via SFTP or HTTPS. Direct Submission Centene also offers posting an 837 batch file directly on the Provider Portal website for processing. Edits and Reports Incoming claims are reviewed first for HIPAA compliance and then for Centene business rules requirements. The business rules that define these requirements are identified in the 837 Professional Data Element Table below, and are also available as a comprehensive list in the 837 Professional Claims – Centene Business Edits Table. HIPAA TR3 implementation guide errors may be returned on either the TA1 or 999 while Centene business edit errors are returned on the Centene Claims Audit Report. Reporting The following table indicates which transaction or report to review for problem data found within the 837 Professional Claim Transaction. Transaction Structure Level Type of Error or Problem Transaction or Report Returned ISA/IEA Interchange Control TA1 GS/GE Functional Group ST/SE Segment Detail Segments HIPAA Implementation Guide violations 999 Centene Claims Audit Report (a proprietary confirmation and error report) Detail Segments Centene Business Edits (see audit report rejection reason codes and explanation.) Centene Claims Audit Report (a proprietary confirmation and error report) Detail Segments HIPAA Implementation Guide violations and Centene Business Edits. 277CA 9 277CA/Audit Report Rejection Codes Error Code Rejection Reason 01 Invalid Mbr DOB 02 Invalid Mbr 06 Invalid Provider 07 Invalid Mbr DOB & Provider 08 Invalid Mbr & Provider 09 Mbr not valid at DOS 10 Invalid Mbr DOB; Mbr not valid at DOS 12 Provider not valid at DOS 13 Invalid Mbr DOB; Prv not valid at DOS 14 Invalid Mbr; Prv not valid at DOS 15 Mbr not valid at DOS; Invalid Prv 16 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Prv 17 Invalid Diag Code 18 Invalid Mbr DOB; Invalid Diag 19 Invalid Mbr; Invalid Diag 21 Mbr not valid at DOS; Prv not valid at DOS 22 Invalid Mbr DOB; Mbr not valid at DOS; Prv not valid at DOS 23 Invalid Prv; Invalid Diagnosis Code 24 Invalid Mbr DOB; Invalid Prv; Invalid Diag Code 25 Invalid Mbr; Invalid Prv; Invalid Diag Code 26 Mbr not valid at DOS; Invalid Diag Code 27 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Diag Code 10 Error Code Rejection Reason 01 Invalid Mbr DOB 02 Invalid Mbr 06 Invalid Provider 07 Invalid Mbr DOB & Provider 29 Provider not valid at DOS; Invalid Diag Code 30 Invalid Mbr DOB; Prv not valid at DOS; Invalid Diag 31 Invalid Mbr; Prv not valid at DOS; Invalid Diag 32 Mbr not valid at DOS; Prv not valid; Invalid Diag 33 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Prv; Invalid Diag 34 Invalid Proc 35 Invalid Mbr DOB; Invalid Proc 36 Invalid Mbr; Invalid Proc 37 Invalid Future Service Date 38 Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag 39 Invalid Mbr DOB; Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag 40 Invalid Prv; Invalid Proc 41 Invalid Mbr DOB, Invalid Prv; Invalid Proc 42 Invalid Mbr; Invalid Prv; Invalid Proc 43 Mbr not valid at DOS; Invalid Proc 44 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Proc 46 Prv not valid at DOS; Invalid Proc 48 Invalid Mbr; Prv not valid at DOS; Invalid Proc 49 Mbr not valid at DOS; Invalid Prv; Invalid Proc 51 Invalid Diag; Invalid Proc 11 Error Code Rejection Reason 01 Invalid Mbr DOB 02 Invalid Mbr 06 Invalid Provider 07 Invalid Mbr DOB & Provider 52 Invalid Mbr DOB; Invalid Diag; Invalid Proc 53 Invalid Mbr; Invalid Diag; Invalid Proc 55 Mbr not valid at DOS; Prv not valid at DOS; Invalid Proc 57 Invalid Prv; Invalid Diag; Invalid Proc 58 Invalid Mbr DOB; Invalid Prv; Invalid Diag; Invalid Proc 59 Invalid Mbr; Invalid Prv; Invalid Diag; Invalid Proc 60 Mbr not valid at DOS;Invalid Diag;Invalid Proc 61 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Diag; Invalid Proc 63 Prv not valid at DOS; Invalid Diag; Invalid Proc 64 Invalid Mbr DOB; Prv not valid at DOS; Invalid Diag; Invalid Proc 65 Invalid Mbr; Prv not valid at DOS; Invalid Diag; Invalid Proc 66 Mbr not valid at DOS; Invalid Prv; Invalid Diag; Invalid Proc 67 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Prv; Invalid Diag; Invalid Proc 72 Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag; Invalid Proc 73 Invalid Mbr DOB; Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag; Invalid Proc 74 Services performed prior to Contract Effective Date 75 Invalid units of service 76 Original Claim Number Required 77 Invalid Claim Type 78 Diagnosis Pointer- Not in sequence or incorrect length 12 Error Code Rejection Reason 01 Invalid Mbr DOB 02 Invalid Mbr 06 Invalid Provider 07 Invalid Mbr DOB & Provider 81 Invalid units of service, Invalid Prv 83 Invalid units of service, Invalid Prv, Invalid Mbr 89 Invalid Mbr DOB; Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag 91 Invalid Missing Taxonomy or NPI/Invalid Prov 92 Invalid Referring/Ordering NPI 93 Mbr not valid at DOS; Invalid Proc 96 GA OPR NPI Registration-State A2 Diagnosis Pointer Invalid A3 Service Lines- Greater than 97 Service lines submitted- Invalid B1 Rendering and Billing NPI are not tied on State File- IN rejection B2 Not enrolled with MHS IN and/or State with rendering NPI/TIN on DOS. Enroll with MHS and Resubmit claim B5 Invalid CLIA C7 NPI Registration- State GA OPR C9 Invalid/Missing Attending NPI HP/H1/H2 ICD9 after end date/ICD10 sent before Eff Date/Mixed ICD versions	508_Centene_5010_837_Companion_Guide.pdf
837 Institutional Companion Guide Version 38.0/July 2016 . 1 Centers for Medicare & Medicaid Services (CMS) Logo. _________________________________________________________________ Medicare Encounter Data System Standard Companion Guide Transaction Information Instructions related to the 837 Health Care Claim: Institutional Transaction based on ASC X12 Technical Report Type 3 (TR3), Version 005010X223A2 Companion Guide Version Number: 38.0 Created: July 2016 837 Institutional Companion Guide Version 38.0/July 2016 . 2 Table of Contents Table of Contents ..........................................................................................................................................................2 Preface................................................................................................................................................................................6 1.0 Introduction .......................................................................................................................................................7 1.1 Scope.................................................................................................................................................................7 1.2 Overview.........................................................................................................................................................7 1.3 Major Updates ..............................................................................................................................................7 1.3.1 EDFES Notifications.....................................................................................................................................7 1.3.2 EDIPPS Edits and EDIPPS Edits Enhancements Implementation Updates................................7 1.3.3 EDIPPS Edits Prevention and Resolution Strategies /Scenarios Updates ..................................8 1.4 References......................................................................................................................................................8 2.0 Contact Information .......................................................................................................................................9 2.1 The Customer Service and Support Center (CSSC) ....................................................................9 2.2 Applicable Websites/Email Resources ............................................................................................9 3.0 File Submission ................................................................................................................................................9 3.1 File Size Limitations ..................................................................................................................................9 3.2 File Structure – NDM/Connect Direct and Gentran/TIBCO Submitters Only ............ 10 4.0 Control Segments/Envelopes................................................................................................................. 10 4.1 ISA/IEA ......................................................................................................................................................... 10 4.2 GS/GE ............................................................................................................................................................ 12 4.3 ST/SE ............................................................................................................................................................. 13 5.0 Transaction Specific Information ......................................................................................................... 13 5.1 837 Institutional: Data Element Table ......................................................................................... 13 6.0 Acknowledgements and/or Reports................................................................................................... 18 6.1 TA1 – Interchange Acknowledgement .......................................................................................... 18 6.2 999 – Functional Group Acknowledgement ............................................................................... 19 6.3 277CA – Claim Acknowledgement .................................................................................................. 19 6.4 MAO-001 – Encounter Data Duplicates Report ........................................................................ 20 6.5 MAO-002 – Encounter Data Processing Status Report.......................................................... 20 6.6 Reports File Naming Conventions ................................................................................................... 21 6.6.1 Testing Reports File Naming Convention .................................................................................. 21 837 Institutional Companion Guide Version 38.0/July 2016 . 3 6.6.2 Production Reports File Naming Convention........................................................................... 22 6.7 EDFES Notifications................................................................................................................................ 23 7.0 Front-End Edits ............................................................................................................................................. 25 7.1 Deactivated Front-End Edits .............................................................................................................. 25 7.2 Temporarily Deactivated Front-End Edits .................................................................................. 28 7.3 New EDFES Edits ..................................................................................................................................... 28 8.0 Duplicate Logic .............................................................................................................................................. 28 8.1 Header Level .............................................................................................................................................. 29 8.2 Detail Level ................................................................................................................................................. 29 9.0 837 Institutional Business Cases .......................................................................................................... 29 9.1 Standard Institutional Encounter .................................................................................................... 31 9.2 Capitated Institutional Encounter ................................................................................................... 33 9.3 Chart Review Institutional Encounter – No Linked ICN ....................................................... 35 9.4 Chart Review Institutional Encounter – Linked ICN (Add Diagnoses) .......................... 37 9.5 Chart Review Institutional Encounter – Linked ICN (Delete Diagnoses) ..................... 39 9.6 Complete Replacement Institutional Encounter ...................................................................... 41 9.7 Complete Deletion Institutional Encounter ................................................................................ 43 9.8 Atypical Provider Institutional Encounter .................................................................................. 45 9.9 Paper Generated Institutional Encounter.................................................................................... 47 9.10 True Coordination of Benefits Institutional Encounter ........................................................ 49 9.11 Bundled Institutional Encounter ..................................................................................................... 51 9.12 Skilled Nursing Facility Encounter.................................................................................................. 53 10.0 Encounter Data Institutional Processing and Pricing System Edits .................................... 55 10.1 EDIPPS Edits Enhancements Implementation Dates ............................................................. 59 10.2 EDIPPS Edits Prevention and Resolution Strategies .............................................................. 59 10.2.1 EDIPPS Edits Prevention and Resolution Strategies – Phase I: Frequently Generated EDIPPS Edits.......................................................................................................................................................... 59 10.2.2 EDIPPS Edits Prevention and Resolution Strategies – Phase II: Common EDPS Edits 61 10.2.3 EDIPPS Edit Prevention and Resolution Strategies–Phase III: General EDIPPS Edits 65 11.0 Submission of Default Data in a Limited Set of Circumstances.............................................. 85 837 Institutional Companion Guide Version 38.0/July 2016 . 4 11.1 Default Data Reason Codes (DDRC)................................................................................................ 85 12.0 Tier II Testing................................................................................................................................................. 86 13.0 EDS Acronyms................................................................................................................................................ 87 837 Institutional Companion Guide Version 38.0/July 2016 . 5 List of Tables TABLE 1 – ISA/IEA INTERCHANGE ELEMENTS ......................................................................................... 11 TABLE 2 – GS/GE FUNCTIONAL GROUP ELEMENTS ............................................................................... 12 TABLE 3 – ST/SE TRANSACTION SET HEADER AND TRAILER ELEMENTS................................. 13 TABLE 4 – 837 INSTITUTIONAL HEALTH CARE CLAIM......................................................................... 14 TABLE 5 – TESTING EDFES REPORTS FILE NAMING CONVENTIONS............................................. 22 TABLE 6 – TESTING EDPS REPORTS FILE NAMING CONVENTIONS ............................................... 22 TABLE 7 – FILE NAME COMPONENT DESCRIPTION................................................................................ 22 TABLE 8 – PRODUCTION EDFES REPORTS FILE NAMING CONVENTIONS .................................. 23 TABLE 9 – PRODUCTION EDPS REPORTS FILE NAMING CONVENTIONS ..................................... 23 TABLE 10 – EDFES NOTIFICATIONS ................................................................................................................ 24 TABLE 11 – 837 INSTITUTIONAL DEACTIVATED EDFES EDITS ....................................................... 26 TABLE 12 – 837 INSTITUTIONAL TEMPORARILY DEACTIVATED edfes EDITS ........................ 28 TABLE 13 – 837 NEW INSTITUTIONAL EDFES EDITS ............................................................................ 28 TABLE 14 – ENCOUNTER DATA INSTITUTIONAL PROCESSING AND PRICING SYSTEM (EDIPPS) EDITS........................................................................................................................................................... 56 TABLE 15 – EDIPPS EDITS ENHANCEMENTS IMPLEMENTATION DATES................................... 59 TABLE 16 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE I .......... 59 TABLE 17 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE II ........ 61 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III ....... 65 TABLE 19 – DEFAULT DATA ................................................................................................................................ 85 TABLE 20 – EDS ACRONYMS................................................................................................................................ 87 TABLE 21 - REVISION HISTORY ......................................................................................................................... 90 837 Institutional Companion Guide Version 38.0/July 2016 . 6 Preface The Encounter Data System (EDS) Companion Guide contains information to assist Medicare Advantage Organizations (MAOs) and other entities in the submission of encounter data. The EDS Companion Guide is continually under development and the information in this version reflects current decisions and will be modified on a regular basis. All of the EDS Companion Guides are identified with a version number, located in the version control log on the last page of the document. Users should verify that they are using the most current version. Questions regarding the content of the EDS Companion Guide should be directed to [email protected]. 837 Institutional Companion Guide Version 38.0/July 2016 . 7 1.0 Introduction 1.1 Scope The Centers for Medicare and Medicaid Services (CMS) EDS 837-I Companion Guide addresses how MAOs and other entities conduct Institutional claims under Health Information Portability and Accountability Act (HIPAA) standard electronic transactions with CMS. The CMS EDS supports transactions adopted under HIPAA, as well as additional supporting transactions described in this guide. The CMS EDS 837-I Companion Guide must be used in conjunction with the associated 837-I Technical Report Type 3 (TR3) and the CMS 5010 Edits Spreadsheets. The instructions in the 837-I CMS EDS Companion Guide are not intended for use as a stand-alone requirements document. 1.2 Overview The CMS EDS 837-I Companion Guide includes information required to initiate and maintain communication exchange with CMS. The information is organized in the sections listed below: • • • • Contact Information: Includes telephone numbers and email addresses for EDS contacts. Control Segments/Envelopes: Contains information required to create the ISA/IEA, GS/GE, and ST/SE control segments in order for transactions to be supported by the EDS. Acknowledgements and Reports: Contains information for all transaction acknowledgements and reports sent by the EDS. Transaction Specific Information: Describes the details of the HIPAA X12 TR3 using a tabular format. The tables contain a row for each segment with CMS and TR3 specific information. That information may contain: o o o o o Limits on the repeat of loops or segments Limits on the length of a simple data element Specifics on a sub-set of the Implementation Guide’s (IG)’s internal code listings Clarification of the use of loops, segments, and composite or simple data elements Any other information tied directly to a loop, segment, and composite or simple data element pertinent to trading electronically with CMS. In addition to the row for each segment, one (1) or more additional rows are used to describe the EDS’ usage for composite or simple data elements and for any other information. 1.3 Major Updates 1.3.1 EDFES Notifications MAOs and other entities may reference Section 6.7, Table 10 for new EDFES notifications. 1.3.2 EDIPPS Edits and EDIPPS Edits Enhancements Implementation Updates MAOs and other entities may reference Section 10.0, Table 14 and Section 10.1, Table 15 for new edits in the EDIPPS. 837 Institutional Companion Guide Version 38.0/July 2016 . 8 1.3.3 EDIPPS Edits Prevention and Resolution Strategies/Scenarios Updates MAOs may reference Section 10.2.3, Table 18 for new and updated Prevention and Resolution Strategies and scenarios for EDIPPS edits. MAOs and other entities must use the ASC X12N TR3 adopted under the HIPAA Administrative Simplification Electronic Transaction rule, along with CMS’ EDS Companion Guides, for development of the EDS transactions. These documents are accessible on the CSSC Operations website at http://www.csscoperations.com. Additionally, CMS publishes the EDS’ submitter guidelines and application, testing documents, and 837 EDS Companion Guides on the CSSC Operations website. 1.4 References MAOs and other entities must use the most current national standard code lists applicable to the 5010 transaction. The code lists is accessible at the Washington Publishing Company (WPC) website at: http://www.wpc-edi.com. The applicable code lists are as follows: • • • Claim Adjustment Reason Code (CARC) Claim Status Category Codes (CSCC) Claim Status Codes (CSC) CMS provides X12 5010 file format technical edit spreadsheets (CMS 5010 Edits Spreadsheets) for the 837-I, 837-P, and 837-DME modules. The edits included in the spreadsheets are provided to clarify the WPC instructions or add Medicare specific requirements. In order to determine the implementation date of the edits contained in the spreadsheet, MAOs and other entities should initially refer to the spreadsheet version identifier. The version identifier is comprised of ten (10) characters, as follows: • Positions 1-2 indicate the line of business: o o o EA – Part A (837-I) EB – Part B (837-P) CE – DME/Part B Drugs • • Positions 3-6 indicate the year (e.g., 2015) Position 7 indicates the release quarter month o o o o 1 – January release 2 – April release 3 – July release 4 – October release • Positions 8-10 indicate the spreadsheet version iteration number (e.g., V01-first iteration, V02- second iteration) The effective date of the spreadsheet is the first calendar day of the release quarter month. The implementation date is the first business Monday of the release quarter month. Federal holidays that potentially occur on the first business Monday are considered when determining the implementation date. 837 Institutional Companion Guide Version 38.0/July 2016 . 9 2.0 Contact Information 2.1 The Customer Service and Support Center (CSSC) The Customer Service and Support Center (CSSC) personnel are available for questions from 8:00 AM – 7:00PM ET, Monday-Friday, with the exception of federal holidays. MAOs and other entities are able to contact the CSSC by phone at 1-877-534-CSSC (2772) or by email at [email protected]. 2.2 Applicable Websites/Email Resources The following websites provide information to assist in the EDS submission: EDS WEBSITE RESOURCES RESOURCE WEB ADDRESS EDS Inbox [email protected] EDS Participant Guide http://www.csscoperations.com/ EDS User Group and Webinar Materials http://www.csscoperations.com/ ANSI ASC X12 TR3 http://www.wpc-edi.com/ Washington Publishing Company Health Care Code Sets http://www.wpc-edi.com/ CMS 5010 Edits Spreadsheets https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/ 3.0 File Submission 3.1 File Size Limitations Due to system limitations, ISA/IEA transaction sets should not exceed 5,000 encounters. Also, it is highly recommended that MAOs and other entities submit larger numbers of encounters within each ST/SE transaction set, not to exceed 5,000 encounters. In an effort to support and provide the most efficient processing system, and to allow for maximum performance, CMS recommends that FTP submitters’ scripts upload no more than one (1) file per five (5) minute intervals. Zipped files should contain one (1) file per transmission. NDM and Gentran/TIBCO users may submit a maximum of 255 files per day. These submission practices will assist with prevention of delays in the generation and distribution of EDFES Acknowledgement reports. Note: Due to system processing overhead associated with smaller numbers of encounters within the ST/SE, it is highly recommended that MAOs and other entities submit larger numbers of encounters within the ST/SE, not to exceed 5,000 encounters. In an effort to support and provide the most efficient processing system, and to allow for maximum performance, CMS recommends that FTP submitters’ scripts upload no more than one (1) file per five (5) minute intervals. Zipped files should contain one (1) file per transmission. MAOs and other entities 837 Institutional Companion Guide Version 38.0/July 2016 . 10 should refrain from submitting multiple files within the same transmission. NDM and Gentran/TIBCO users may submit a maximum of 255 files per day. 3.2 File Structure – NDM/Connect Direct and Gentran/TIBCO Submitters Only NDM/Connect Direct and Gentran/TIBCO submitters must format all submitted files in an 80-byte fixed block format. This means MAOs and other entities must upload every line (record) in a file with a length of 80 bytes/characters. Submitters should create files with segments stacked, using only 80 characters per line. At position 81 of each segment, MAOs and other entities must create a new line. On the new line starting in position 1, continue for 80 characters, and repeat creating a new line in position 81 until the file is complete. If the last line in the file does not fill to 80 characters, the submitter should space the line out to position 80 and then save	Jul2016_CG_837I_5CR_081016.pdf
The implementation date is the first business Monday of the release quarter month. Federal holidays that potentially occur on the first business Monday are considered when determining the implementation date. 837 Institutional Companion Guide Version 38.0/July 2016 . 9 2.0 Contact Information 2.1 The Customer Service and Support Center (CSSC) The Customer Service and Support Center (CSSC) personnel are available for questions from 8:00 AM – 7:00PM ET, Monday-Friday, with the exception of federal holidays. MAOs and other entities are able to contact the CSSC by phone at 1-877-534-CSSC (2772) or by email at [email protected]. 2.2 Applicable Websites/Email Resources The following websites provide information to assist in the EDS submission: EDS WEBSITE RESOURCES RESOURCE WEB ADDRESS EDS Inbox [email protected] EDS Participant Guide http://www.csscoperations.com/ EDS User Group and Webinar Materials http://www.csscoperations.com/ ANSI ASC X12 TR3 http://www.wpc-edi.com/ Washington Publishing Company Health Care Code Sets http://www.wpc-edi.com/ CMS 5010 Edits Spreadsheets https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/ 3.0 File Submission 3.1 File Size Limitations Due to system limitations, ISA/IEA transaction sets should not exceed 5,000 encounters. Also, it is highly recommended that MAOs and other entities submit larger numbers of encounters within each ST/SE transaction set, not to exceed 5,000 encounters. In an effort to support and provide the most efficient processing system, and to allow for maximum performance, CMS recommends that FTP submitters’ scripts upload no more than one (1) file per five (5) minute intervals. Zipped files should contain one (1) file per transmission. NDM and Gentran/TIBCO users may submit a maximum of 255 files per day. These submission practices will assist with prevention of delays in the generation and distribution of EDFES Acknowledgement reports. Note: Due to system processing overhead associated with smaller numbers of encounters within the ST/SE, it is highly recommended that MAOs and other entities submit larger numbers of encounters within the ST/SE, not to exceed 5,000 encounters. In an effort to support and provide the most efficient processing system, and to allow for maximum performance, CMS recommends that FTP submitters’ scripts upload no more than one (1) file per five (5) minute intervals. Zipped files should contain one (1) file per transmission. MAOs and other entities 837 Institutional Companion Guide Version 38.0/July 2016 . 10 should refrain from submitting multiple files within the same transmission. NDM and Gentran/TIBCO users may submit a maximum of 255 files per day. 3.2 File Structure – NDM/Connect Direct and Gentran/TIBCO Submitters Only NDM/Connect Direct and Gentran/TIBCO submitters must format all submitted files in an 80-byte fixed block format. This means MAOs and other entities must upload every line (record) in a file with a length of 80 bytes/characters. Submitters should create files with segments stacked, using only 80 characters per line. At position 81 of each segment, MAOs and other entities must create a new line. On the new line starting in position 1, continue for 80 characters, and repeat creating a new line in position 81 until the file is complete. If the last line in the file does not fill to 80 characters, the submitter should space the line out to position 80 and then save the file. Note: If MAOs and other entities are using a text editor to create the file, pressing the Enter key will create a new line. If MAOs and other entities are using an automated system to create the file, create a new line by using a CRLF (Carriage Return Line Feed) or a LF (Line Feed). For example, the ISA record is 106 characters long: The first line of the file will contain the first 80 characters of the ISA segment; the last 26 characters of the ISA segment continue on the second line. The next segment will start in the 27th position and continue until column 80. ISA00 00 ZZ ENH9999ZZ80881 120816114 4^005010000000311P:~ Note to NDM/Connect:Direct Users: If a submitter has not established a sufficient number of Generated Data Groups (GDGs) to accommodate the number of files returned from the EDFES, not all of the EDFES Acknowledgement reports will be stored in the submitter’s system. To prevent this situation, NDM/Connect:Direct submitters should establish a limit of 255 GDGs in their internal processing systems. 4.0 Control Segments/Envelopes 4.1 ISA/IEA The term interchange denotes the transmitted ISA/IEA envelope. Interchange control is achieved through several “control” components, as defined in Table 1. The interchange control number is contained in data element ISA13 of the ISA segment. The identical control number must also occur in data element IEA02 of the IEA segment. MAOs and other entities must populate all elements in the ISA/IEA interchange. There are several elements within the ISA/IEA interchange that must be populated specifically for encounter data purposes. Table 1 below provides EDS Interchange Control (ISA/IEA) specific elements. Note: Table 1 presents only those elements that provide specific details relevant to encounter data. When developing the encounter data system, users should base their logic on the highest level of specificity. First, consult the WPC/TR3. Second, consult the CMS 5010 Edits Spreadsheets. Third, 837 Institutional Companion Guide Version 38.0/July 2016 . 11 consult the CMS EDS 837-I Companion Guide. If there are options expressed in the WPC/TR3 or the CMS 5010 Edits Spreadsheets that are broader than the options identified in the CMS EDS 837-I Companion Guide, MAOs and other entities must use the rules identified in the Companion Guide. LEGEND TO TABLE 1 Legend SHADED rows represent segments in the X12N TR3 NON-SHADED rows represent data elements in the X12N TR3 TABLE 1 – ISA/IEA INTERCHANGE ELEMENTS LOOP ID REFERENCE NAME CODES NOTES/COMMENTS ISA N/A Interchange Control Header N/A N/A ISA ISA01 Authorization Information Qualifier 00 No authorization information present LOOP ID REFERENCE NAME CODES NOTES/COMMENTS ISA ISA02 Authorization Information N/A Use 10 blank spaces ISA ISA03 Security Information Qualifier 00 No security information present ISA ISA04 Security Information N/A Use 10 blank spaces ISA ISA05 Interchange ID Qualifier ZZ CMS expects to see a value of “ZZ” to designate that the code is mutually defined ISA ISA06 Interchange Sender ID N/A EN followed by Contract ID Number ISA ISA08 Interchange Receiver ID 80881 N/A ISA ISA11 Repetition Separator ^ N/A ISA ISA13 Interchange Control Number N/A Must be fixed length with nine (9) characters and match IEA02 Used to identify file level duplicate collectively with GS06, ST02, and BHT03 ISA ISA14 Acknowledgement Requested 1 A TA1 will be sent if the file is syntactically incorrect, otherwise only a ‘999’ will be sent ISA ISA15 Usage Indicator T P Test Production IEA N/A Interchange Control Trailer N/A N/A IEA IEA02 Interchange Control Number N/A Must match the value in ISA13 837 Institutional Companion Guide Version 38.0/July 2016 . 12 4.2 GS/GE The functional group is outlined by the functional group header (GS segment) and the functional group trailer (GE segment). The functional group header starts and identifies one or more related transaction sets and provides a control number and application identification information. The functional group trailer defines the end of the functional group of related transaction sets and provides a count of contained transaction sets. MAOs and other entities must populate all elements in the GS/GE functional group. There are several elements within the GS/GE that must be populated specifically for encounter data collection. Table 2 provides EDS functional group (GS/GE) specific elements. Note: Table 2 presents only those elements that require explanation. TABLE 2 – GS/GE FUNCTIONAL GROUP ELEMENTS LOOP ID REFERENCE NAME CODES NOTES/COMMENTS GS N/A Functional Group Header N/A N/A GS GS02 Application Sender’s Code N/A EN followed by Contract ID Number This value must match the value in the ISA06 GS GS03 Application Receiver’s Code 80881 This value must match the value in ISA08 GS GS06 Group Control Number N/A This value must match the value in GE02 Used to identify file level duplicates collectively with ISA13, ST02, and BHT03 GS GS08 Version/Release/Industry Identifier Code 005010X223A2 N/A GE N/A Functional Group Trailer N/A N/A GE GE02 Group Control Number N/A This value must match the value in GS06 837 Institutional Companion Guide Version 38.0/July 2016 . 13 4.3 ST/SE The transaction set (ST/SE) contains required, situational loops, unused loops, segments, and data elements. The transaction set is outlined by the transaction set header (ST segment) and the transaction set trailer (SE segment). The transaction set header identifies the start and identifies the transaction set. The transaction set trailer identifies the end of the transaction set and provides a count of the data segments, which includes the ST and SE segments. Several elements must be populated specifically for encounter data purposes. Table 3 provides EDS transaction set (ST/SE) specific elements. Note: Table 3 presents only those elements that require explanation. TABLE 3 – ST/SE TRANSACTION SET HEADER AND TRAILER ELEMENTS LOOP ID REFERENCE NAME CODES NOTES/COMMENTS ST N/A Transaction Set Header N/A N/A ST ST01 Transaction Set Identifier Code 837 N/A ST ST02 Transaction Set Control Number N/A This value must match the value in SE02 Used to identify file level duplicates collectively with ISA13, GS06, and BHT03 ST ST03 Implementation Convention Reference 005010X223A2 N/A SE N/A Transaction Set Trailer N/A N/A SE SE01 Number of Included Segments N/A Must contain the actual number of segments within the ST/SE SE SE02 Transaction Set Control Number N/A This value must be match the value in ST02 5.0 Transaction Specific Information 5.1 837 Institutional: Data Element Table Within the ST/SE transaction set, there are multiple loops, segments, and data elements that provide billing provider, subscriber, and patient level information. MAOs and other entities should reference www.wpc-edi.com to obtain the most current TR3. MAOs and other entities must submit EDS transactions using the most current transaction version. The 837 Institutional Data Element table identifies only those elements within the X12N TR3 that require comment within the context of the EDS’ submission. Table 4 identifies the 837 Institutional TR3 by loop name, segment name, segment identifier, data element name, and data element identifier for cross reference. Not all data elements listed in the table below are required, but if they are used, the table reflects the values CMS expects to see. 837 Institutional Companion Guide Version 38.0/July 2016 . 14 TABLE 4 – 837 INSTITUTIONAL HEALTH CARE CLAIM LOOP ID REFERENCE NAME CODES NOTES/COMMENTS N/A BHT Beginning of Hierarchical Transaction N/A N/A N/A BHT03 Originator Application Transaction Identifier N/A Must be a unique identifier across all files Used to identify file level duplicates collectively with ISA13, GS06, and ST02. N/A BHT06 Claim Identifier CH Chargeable 1000A NM1 Submitter Name N/A N/A 1000A NM102 Entity Type Qualifier 2 Non-Person Entity 1000A NM109 Submitter Identifier N/A EN followed by Contract ID Number 1000A PER Submitter EDI Contact Info N/A N/A 1000A PER03 Communication Number Qualifier TE It is recommended that MAOs and other entities populate the submitter’s telephone number 1000A PER05 Communication Number Qualifier EM It is recommended that MAOs and other entities populate the submitter’s email address 1000A PER Submitter EDI Contact Information N/A N/A 1000A PER07 Communication Number Qualifier FX It is recommended that MAOs and other entities populate the submitter’s fax number 1000B NM1 Receiver Name N/A N/A 1000B NM102 Entity Type Qualifier 2 Non-Person Entity 1000B NM103 Receiver Name N/A EDSCMS 1000B NM109 Receiver ID 80881 Identifies CMS as the receiver of the transaction and corresponds to the value in ISA08 Interchange Receiver ID. When the Payer ID must be changed for an encounter submitted to the EDS, MAOs and other entities must first void the original encounter, then submit a new encounter with the correct Payer ID.A 2010AA NM1 Billing Provider Name N/A N/A 2010AA NM108 Billing Provider ID Qualifier XX NPI Identifier 2010AA NM109 Billing Provider Identifier 1XXXXXXXXX Must be populated with a ten digit number, must begin with 1 Note: Default NPIs should only be submitted to the EDS when the 837 Institutional Companion Guide Version 38.0/July 2016 . 15 LOOP ID REFERENCE NAME CODES NOTES/COMMENTS provider is considered to be “atypical.” Institutional Default NPI: 1999999976 2010AA N4 Billing Provider City, State, Zip Code N/A N/A 2010AA N403 Zip Code N/A The full nine (9) digits of the ZIP Code are required. If the last four (4) digits of the ZIP code are not available, populate a default value of “9998”. 2010AA REF Billing Provider Tax Identification Number N/A N/A 2010AA REF01 Reference Identification Qualifier EI Employer’s Identification Number (EIN) 2010AA	Jul2016_CG_837I_5CR_081016.pdf
match the value in ST02 5.0 Transaction Specific Information 5.1 837 Institutional: Data Element Table Within the ST/SE transaction set, there are multiple loops, segments, and data elements that provide billing provider, subscriber, and patient level information. MAOs and other entities should reference www.wpc-edi.com to obtain the most current TR3. MAOs and other entities must submit EDS transactions using the most current transaction version. The 837 Institutional Data Element table identifies only those elements within the X12N TR3 that require comment within the context of the EDS’ submission. Table 4 identifies the 837 Institutional TR3 by loop name, segment name, segment identifier, data element name, and data element identifier for cross reference. Not all data elements listed in the table below are required, but if they are used, the table reflects the values CMS expects to see. 837 Institutional Companion Guide Version 38.0/July 2016 . 14 TABLE 4 – 837 INSTITUTIONAL HEALTH CARE CLAIM LOOP ID REFERENCE NAME CODES NOTES/COMMENTS N/A BHT Beginning of Hierarchical Transaction N/A N/A N/A BHT03 Originator Application Transaction Identifier N/A Must be a unique identifier across all files Used to identify file level duplicates collectively with ISA13, GS06, and ST02. N/A BHT06 Claim Identifier CH Chargeable 1000A NM1 Submitter Name N/A N/A 1000A NM102 Entity Type Qualifier 2 Non-Person Entity 1000A NM109 Submitter Identifier N/A EN followed by Contract ID Number 1000A PER Submitter EDI Contact Info N/A N/A 1000A PER03 Communication Number Qualifier TE It is recommended that MAOs and other entities populate the submitter’s telephone number 1000A PER05 Communication Number Qualifier EM It is recommended that MAOs and other entities populate the submitter’s email address 1000A PER Submitter EDI Contact Information N/A N/A 1000A PER07 Communication Number Qualifier FX It is recommended that MAOs and other entities populate the submitter’s fax number 1000B NM1 Receiver Name N/A N/A 1000B NM102 Entity Type Qualifier 2 Non-Person Entity 1000B NM103 Receiver Name N/A EDSCMS 1000B NM109 Receiver ID 80881 Identifies CMS as the receiver of the transaction and corresponds to the value in ISA08 Interchange Receiver ID. When the Payer ID must be changed for an encounter submitted to the EDS, MAOs and other entities must first void the original encounter, then submit a new encounter with the correct Payer ID.A 2010AA NM1 Billing Provider Name N/A N/A 2010AA NM108 Billing Provider ID Qualifier XX NPI Identifier 2010AA NM109 Billing Provider Identifier 1XXXXXXXXX Must be populated with a ten digit number, must begin with 1 Note: Default NPIs should only be submitted to the EDS when the 837 Institutional Companion Guide Version 38.0/July 2016 . 15 LOOP ID REFERENCE NAME CODES NOTES/COMMENTS provider is considered to be “atypical.” Institutional Default NPI: 1999999976 2010AA N4 Billing Provider City, State, Zip Code N/A N/A 2010AA N403 Zip Code N/A The full nine (9) digits of the ZIP Code are required. If the last four (4) digits of the ZIP code are not available, populate a default value of “9998”. 2010AA REF Billing Provider Tax Identification Number N/A N/A 2010AA REF01 Reference Identification Qualifier EI Employer’s Identification Number (EIN) 2010AA REF02 Billing Provider Tax Identification Number XXXXXXXXX Must be populated with XXXXXXXXX. Note: Default EINs should only be submitted to the EDS when the provider is considered “atypical.” Institutional Default EIN: 199999997 2000B SBR Subscriber Information N/A N/A 2000B SBR01 Payer Responsibility Number Code S EDSCMS is considered the destination (secondary) payer 2000B SBR09 Claim Filing Indicator Code MA Must be populated with a value of MA – Medicare Part A 2010BA NM1 Subscriber Name N/A N/A 2010BA NM108 Subscriber Id Qualifier MI Must be populated with a value of MI – Member Identification Number 2010BA NM109 Subscriber Primary Identifier N/A This is the subscriber’s Health Insurance Claim (HIC) number. Must match the value in Loop 2330A, NM109 2010BB NM1 Payer Name N/A N/A 2010BB NM103 Payer Name N/A EDSCMS 2010BB NM108 Payer ID Qualifier PI Must be populated with the value of PI – Payer Identification 2010BB NM109 Payer Identification 80881 When the Payer ID must be changed for an encounter submitted to the EDS, MAOs and other entities must first void the original encounter, then submit a new encounter with the correct Payer ID. 2010BB N3 Payer Address N/A N/A 2010BB N301 Payer Address Line 7500 Security Blvd N/A 837 Institutional Companion Guide Version 38.0/July 2016 . 16 LOOP ID REFERENCE NAME CODES NOTES/COMMENTS 2010BB N4 Payer City, State, ZIP Code N/A N/A 2010BB N401 Payer City Name Baltimore N/A 2010BB N402 Payer State MD N/A 2010BB N403 Payer ZIP Code 212441850 N/A 2010BB REF Other Payer Secondary Identifier N/A N/A 2010BB REF01 Contract ID Identifier 2U N/A 2010BB REF02 Contract ID Number N/A MAO or other entities Contract ID Number 2300 CLM Claim Information N/A N/A 2300 CLM02 Total Claim Charge Amount N/A N/A 2300 CLM05-3 Claim Frequency Type Code 1 2 3 4 7 8 9 1=Original claim submission 2=Interim – First Claim 3=Interim – Continuing Claim 4=Interim – Last Claim 7=Replacement 8=Void 9=Final Claim for a Home Health PPS Episode 2300 DTP Date – Admission Date/Hour N/A N/A 2300 DTP02 Date Time Period Format Qualifier D8 DT D8=CCYYMMDD DT=CCYYMMDDHHMM 2300 DTP03 Admission Date/Hour N/A Hours (HH) are expressed as “00” for midnight, “01” for 1A.M., and so on through “23” for 11P.M. Minutes (MM) are expressed as “00” through “59”. If the actual minutes are not known, use a default of “00”. This is only required for original or final bills 2300 PWK Claim Supplemental Info N/A N/A 2300 PWK01 Report Type Code 09 OZ PY Populated for chart review submissions only Populated for encounters generated as a result of paper claims only Populated for encounters generated as a result of 4010 submission only 2300 PWK02 Attachment Transmission Code AA Populated for chart review, paper generated, and 4010 generated encounters 2300 CN1 Contract Information N/A N/A 2300 CN101 Contract Type Code 05 Populated for capitated/ staff model arrangements 2300 REF Payer Claim Control Number N/A N/A 2300 REF01 Original Reference Number F8 N/A 837 Institutional Companion Guide Version 38.0/July 2016 . 17 LOOP ID REFERENCE NAME CODES NOTES/COMMENTS 2300 REF02 Payer Claim Control Number N/A Identifies ICN from original encounter when submitting void or replacement EDR or chart review data EDR 2300 REF Medical Record Number N/A N/A 2300 REF01 Medical Record Identification Number EA N/A 2300 REF02 Medical Record Identification Number 8 Chart review delete diagnosis code only submission – Identifies the diagnosis code populated in Loop 2300, HI must be deleted from the encounter ICN in Loop 2300, REF02. 2300 NTE Claim Note N/A N/A 2300 NTE01 Note Reference Code ADD N/A 2300 NTE02 Claim Note Text N/A See Section 11.0 for the use and message requirements of default data information 2300 HI Value Information N/A N/A 2300 HI01-2 Value Code A0 Required on all ambulance encounters 2300 HI01-5 Value Code Amount N/A If available, the ambulance pick-up location ZIP Code+4 should be provided. The ZIP code must be in the following format: XXXXXXX.XX (If a valid +4 cannot be populated, use ‘9998’ as the +4 extension (XXXXX99.98)). 2320 SBR Other Subscriber Information N/A N/A 2320 SBR01 Payer Responsibility Sequence Number Code P T P=Primary (when MAOs or other entities populate the payer paid amount) T=Tertiary (when MAOs or other entities populate a true COB) 2320 SBR09 Claim Filing Indicator Code 16 Health Maintenance Organization (HMO) Medicare Risk 2330A NM1 Other Subscriber Name N/A N/A 2330A NM108 Identification Code Qualifier MI N/A 2330A NM109 Subscriber Primary Identifier N/A Must match the value in Loop 2010BA, NM109 2330B NM1 Other Payer Name N/A N/A 2330B NM108 Identification Code Qualifier XV N/A 2330B NM109 Other Payer Primary Identifier Payer 01 MAO or other entity’s Contract ID Number. Only populated if there is no Contract ID Number available for a true other payer 837 Institutional Companion Guide Version 38.0/July 2016 . 18 LOOP ID REFERENCE NAME CODES NOTES/COMMENTS 2330B N3 Other Payer Address N/A N/A 2330B N301 Other Payer Address Line N/A MAO or other entity’s address 2330B N4 Other Payer City, State, ZIP Code N/A N/A 2330B N401 Other Payer City Name N/A MAO or other entity’s City Name 2330B N402 Other Payer State N/A MAO or other entity’s State 2330B N403 Other Payer ZIP Code N/A MAO or other entity’s ZIP Code 2430 SVD Line Adjudication Information N/A N/A 2430 SVD01 Other Payer Primary Identifier N/A Must match the value in Loop 2330B, NM109 2430 CAS Line Adjustments N/A N/A 2430 CAS02 Adjustment Reason Code N/A If a service line is denied in the MAO’s or other entity’s adjudication system, the denial reason must be populated 2430 DTP Line Check or Remittance Date N/A N/A 2430 DTP03 N/A N/A Populate the claim receipt date minus one (1) day as the default primary payer adjudication date only in the instance that the primary payer adjudication date is not available 6.0 Acknowledgements and/or Reports 6.1 TA1 – Interchange Acknowledgement The TA1 report enables the receiver to notify the sender when there are problems with the interchange control structure. As the interchange envelope enters the EDFES, the EDI translator performs TA1 validation of the control segments/envelope. The sender will only receive a TA1 there are syntax errors in the file. Errors found in this stage will cause the entire X12 interchange to be rejected with no further processing. MAOs and other entities will receive a TA1 interchange report acknowledging the syntactical inaccuracy of an X12 interchange header ISA and trailer IEA and the envelope’s structure. Encompassed in the TA1 is the interchange control number, interchange date and time, interchange acknowledgement code, and interchange note code. The interchange control number, date, and time are identical to those populated on the original 837-I or 837-P ISA line, which allows for MAOs and other entities to associate the TA1 with a specific file previously submitted. Within the TA1 segment, MAOs and other entities will be able to determine if the interchange rejected by examining the interchange acknowledgement code (TA104) and the interchange note code (TA105). The interchange acknowledgement code stipulates whether the interchange (ISA/IEA) rejected due to syntactical errors. An “R” will be the value in the TA104 data element if the interchange rejected due to syntactical errors. The interchange note code is a numeric code that notifies MAOs and other entities of the specific error. If a fatal error occurs, the EDFES generates and returns the TA1 interchange acknowledgement report within 24 hours of the interchange submission. If a TA1 interchange control 837 Institutional Companion Guide Version 38.0/July 2016 . 19 structure error is identified, MAOs and other entities must correct the error and resubmit the interchange file. 6.2 999 – Functional Group Acknowledgement After the interchange passes the TA1 edits, the next stage of editing is to apply Common Edits and Enhancements Module (CEM) edits and verify the syntactical accuracy of the functional group(s) (GS/GE). Functional groups allow for organization of like data within an interchange; therefore, more than one (1) functional group containing multiple claims within the functional group can be populated in a file. The 999 acknowledgement report provides information on the validation of the GS/GE functional group(s) and the consistency of the data. The 999 report provides MAOs and other entities information on whether the functional groups were accepted or rejected. If a file has multiple GS/GE segments and errors occurred at any point within one (1) of the syntactical and IG level edit validations, the GS/GE segment will reject, and processing will continue to the next GS/GE segment. For instance, if a file is submitted with three (3) functional groups and there are errors in the second functional, the first functional group will accept, the second functional group will reject, and processing will continue to the third functional group. The 999 transaction set is designed to report on adherence to IG level edits and CMS standard syntax errors as depicted in the CMS 5010 Edits Spreadsheets. Three (3) possible acknowledgement values are: • • • “A” – Accepted “R” – Rejected “P” – Partially Accepted, At Least One (1) Transaction Set Was Rejected When viewing the 999 report, MAOs and other entities should navigate to the IK5 and AK9 segments. If an “A” is displayed in the IK5 and AK9 segments, the claim file is accepted and will continue processing.	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found in this stage will cause the entire X12 interchange to be rejected with no further processing. MAOs and other entities will receive a TA1 interchange report acknowledging the syntactical inaccuracy of an X12 interchange header ISA and trailer IEA and the envelope’s structure. Encompassed in the TA1 is the interchange control number, interchange date and time, interchange acknowledgement code, and interchange note code. The interchange control number, date, and time are identical to those populated on the original 837-I or 837-P ISA line, which allows for MAOs and other entities to associate the TA1 with a specific file previously submitted. Within the TA1 segment, MAOs and other entities will be able to determine if the interchange rejected by examining the interchange acknowledgement code (TA104) and the interchange note code (TA105). The interchange acknowledgement code stipulates whether the interchange (ISA/IEA) rejected due to syntactical errors. An “R” will be the value in the TA104 data element if the interchange rejected due to syntactical errors. The interchange note code is a numeric code that notifies MAOs and other entities of the specific error. If a fatal error occurs, the EDFES generates and returns the TA1 interchange acknowledgement report within 24 hours of the interchange submission. If a TA1 interchange control 837 Institutional Companion Guide Version 38.0/July 2016 . 19 structure error is identified, MAOs and other entities must correct the error and resubmit the interchange file. 6.2 999 – Functional Group Acknowledgement After the interchange passes the TA1 edits, the next stage of editing is to apply Common Edits and Enhancements Module (CEM) edits and verify the syntactical accuracy of the functional group(s) (GS/GE). Functional groups allow for organization of like data within an interchange; therefore, more than one (1) functional group containing multiple claims within the functional group can be populated in a file. The 999 acknowledgement report provides information on the validation of the GS/GE functional group(s) and the consistency of the data. The 999 report provides MAOs and other entities information on whether the functional groups were accepted or rejected. If a file has multiple GS/GE segments and errors occurred at any point within one (1) of the syntactical and IG level edit validations, the GS/GE segment will reject, and processing will continue to the next GS/GE segment. For instance, if a file is submitted with three (3) functional groups and there are errors in the second functional, the first functional group will accept, the second functional group will reject, and processing will continue to the third functional group. The 999 transaction set is designed to report on adherence to IG level edits and CMS standard syntax errors as depicted in the CMS 5010 Edits Spreadsheets. Three (3) possible acknowledgement values are: • • • “A” – Accepted “R” – Rejected “P” – Partially Accepted, At Least One (1) Transaction Set Was Rejected When viewing the 999 report, MAOs and other entities should navigate to the IK5 and AK9 segments. If an “A” is displayed in the IK5 and AK9 segments, the claim file is accepted and will continue processing. If an “R” is displayed in the IK5 and AK9 segments, an IK3 and an IK4 segment will be displayed. These segments indicate what loops and segments contain the error that requires correction so the interchange can be resubmitted. The third element in the IK3 segment identifies the loop that contains the error. The first element in the IK3 and IK4 indicates the segment and element that contain the error. The third element in the IK4 segment indicates the reason code for the error. 6.3 277CA – Claim Acknowledgement After the file is accepted at the interchange and functional group levels, the third level of editing occurs at the transaction set level within the CEM in order to create the Claim Acknowledgement Transaction (277CA) report. The CEM checks the validity of the values within the data elements. For instance, data element N403 must be a valid nine (9)-digit ZIP code. If a non-existent ZIP code is populated, the CEM will reject the encounter. The 277CA is an unsolicited acknowledgement report from CMS to MAOs and other entities. The 277CA is used to acknowledge the acceptance or rejection of encounters submitted using a hierarchical level (HL) structure. The first level of hierarchical editing is at the Information Source level. This entity is the decision maker in the business transaction receiving the X12 837 transactions (EDSCMS). The next level is at the Information Receiver level. This is the entity expecting the response from the Information Source. The third hierarchal level is at the Billing Provider of Service level; and the fourth and final level is done at the Patient level. Acceptance or rejection at this level is based on the WPC and the CMS 5010 Edits Spreadsheets. Edits received at any hierarchical level will stop and no further editing will take place. For example, if there is a problem with the Billing Provider of Service 837 Institutional Companion Guide Version 38.0/July 2016 . 20 submitted on the 837, individual patient edits will not be performed. For those encounters not accepted, the 277CA will detail additional actions required of MAOs and other entities in order to correct and resubmit those encounters. If an MAO or other entity receives a 277CA indicating that an encounter was rejected, the MAO or other entity must resubmit the encounter until the 277CA indicates no errors were found. If an encounter is accepted, the 277CA will provide the ICN assigned to that encounter. The ICN segment for the accepted encounter will be located in 2200D REF segment, REF01=IK and REF02=ICN. The ICN is a unique 13-digit number. If an encounter rejects, the 277CA will provide edit information in the STC segment. The STC03 data element will convey whether the HL structures accepted or rejected. The STC03 is populated with a value of “WQ” if the HL was accepted. If the STC03 data element is populated with a value of “U”, the HL is rejected and the STC01 data element will list the acknowledgement code. 6.4 MAO-001 – Encounter Data Duplicates Report When the MAO-002 Encounter Data Processing Status Report is returned to an MAO or other entity, and contains one or more the following edits, • • • • 98300 – Exact Inpatient Duplicate Encounter, 98315 – Linked Chart Review Duplicate, 98320 – Chart Review Duplicate, or 98325 – Service Line(s) Duplicated, the EDPS will also generate and return the MAO-001 Encounter Data Duplicates Report. MAOs and other entities will not receive the MAO-001 report if there are no duplicate errors received on submitted encounters. The MAO-001 report is a fixed length report available in flat file and formatted report layouts. It provides information for encounters and service lines that receive a status of “reject” and specific error messages 98300, 98315, 98320, or 98325. MAOs and other entities must correct and resubmit only those encounters that received edits 98300, 98315, 98320, or 98325. The MAO-001 report allows MAOs and other entities the opportunity to more easily reconcile these duplicate encounters and service lines. 6.5 MAO-002 – Encounter Data Processing Status Report After a file accepts through the EDFES, the file is transmitted to the Encounter Data Processing System (EDPS) where further editing, processing, pricing, and storage occurs. As a result of EDPS editing, the EDPS will return the MAO-002 – Encounter Data Processing Status Report. The MAO-002 report is a fixed length report available in flat file and formatted report layouts that provide encounter and service line level information. The MAO-002 reflects two (2) statuses at the encounter and service line level: “accepted” or “rejected”. Lines that reflect a status of “accept” yet contain an error message in the Error Description column are considered “informational” edits. MAOs and other entities are not required to take further action on “informational” edits; however, they are encouraged to do so to ensure accuracy of internal claims processing data. The ‘000’ line on the MAO-002 report identifies the header level and indicates either “accepted” or “rejected” status. If the ‘000’ header line is rejected, the encounter is considered rejected and MAOs 837 Institutional Companion Guide Version 38.0/July 2016 . 21 and other entities must correct and resubmit the encounter. If the ‘000’ header line is “accepted” and at least one (1) other line (i.e., 001 002 003 004) is accepted, then the overall encounter is accepted. 6.6 Reports File Naming Conventions In order for MAOs and other entities to receive and identify the EDFES Acknowledgement Reports (TA1, 999 and 277CA) and EDPS MAO-002 Encounter Data Processing Status Reports, specific reports file naming conventions have been used. The file name ensures that the specific reports are appropriately distributed to each secure, unique mailbox. The EDFES and EDPS have established unique file naming conventions for reports distributed during testing and production. 6.6.1 Testing Reports File Naming Convention Table 5 below provides the EDFES reports file naming conventions according to connectivity method. MAOs and other entities should note that Connect:Direct (NDM) users’ reports file naming conventions are user defined. 837 Institutional Companion Guide Version 38.0/July 2016 . 22 TABLE 5 – TESTING EDFES REPORTS FILE NAMING CONVENTIONS REPORT TYPE GENTRAN/TIBCO MAILBOX FTP MAILBOX EDFES Notifications T.xxxxx.EDS_RESPONSE.pn RSPxxxxx.RSP.REJECTED_ID TA1 T.xxxxx.EDS_REJT_IC_ISAIEA.pn X12xxxxx.X12.TMMDDCCYYHHMMS 999 T.xxxxx.EDS_REJT_FUNCT_TRANS.pn 999#####.999.999 999 T.xxxxx.EDS_ACCPT_FUNCT_TRANS.pn 999#####.999.999 277CA T.xxxxx.EDS_RESP_CLAIM_NUM.pn RSPxxxxx.RSP_277CA Table 6 below provides the EDPS reports file naming conventions by connectivity method. MAOs and other entities should note that Connect:Direct (NDM) users’ reports file naming conventions are user defined. TABLE 6 – TESTING EDPS REPORTS FILE NAMING CONVENTIONS Table 7 below provides a description of the file name components, which will assist MAOs and other entities in identifying the report types. TABLE 7 – FILE NAME COMPONENT DESCRIPTION FILE NAME COMPONENT DESCRIPTION RSPxxxxx The type of data ‘RSP’ and a sequential number assigned by the server ‘xxxxx’ X12xxxxx The type of data ‘X12’ and a sequential number assigned by the server ‘xxxxx’ TMMDDCCYYHHMMS The Date and Time stamp the file was processed 999xxxxx The type of data ‘999’ and a sequential number assigned by the server ‘xxxxx’ RPTxxxxx The type of data ‘RPT’ and a sequential number assigned by the server ‘xxxxx’ EDPS_XXX Identifies the specific EDPS Report along with the report number (i.e., ‘002’, etc.) XXXXXXX Seven (7) characters available to be used as a short description of the contents of the file RPT/FILE Identifies if the file is a formatted report ‘RPT’ or a flat file ‘FILE’ layout 6.6.2 Production Reports File Naming Convention A different production reports file naming convention is used so that MAOs and other entities may easily identify reports generated and distributed during production. Table 8 below provides the reports file naming conventions per connectivity method for production reports. CONNECTIVITY METHOD TESTING NAMING CONVENTION FORMATTED REPORT TESTING NAMING CONVENTION FLAT FILE LAYOUT GENTRAN/ TIBCO T .xxxxx.EDPS_001_DataDuplicate_Rpt T.xxxxx.EDPS_002_DataProcessingStatus_Rpt T .xxxxx.EDPS_004_RiskFilter_Rpt T.xxxxx.EDPS_005_DispositionSummary_Rpt T .xxxxx.EDPS_006_EditDisposition_Rpt T .xxxxx.EDPS_007_DispositionDetail_Rpt T .xxxxx.EDPS_001_DataDuplicate_File T.xxxxx.EDPS_002_DataProcessingStatus_File T .xxxxx.EDPS_004_RiskFilter_File T.xxxxx.EDPS_005_DispositionSummary_ File T .xxxxx.EDPS_006_EditDisposition_ File T .xxxxx.EDPS_007_DispositionDetail_ File FTP RPTxxxxx.RPT.EDPS_001_DATDUP_RPT RPTxxxxx.RPT.EDPS_002_DATPRS_RPT RPTxxxxx.RPT.EDPS_004_RSKFLT_RPT RPTxxxxx.RPT.EDPS_005_DSPSUM_RPT RPTxxxxx.RPT.EDPS_006_EDTDSP_RPT RPTxxxxx.RPT.EDPS_007_DSTDTL_RPT RPTxxxxx.RPT.EDPS_001_DATDUP_File RPTxxxxx.RPT.EDPS_002_DATPRS_File RPTxxxxx.RPT.EDPS_004_RSKFLT_ File RPTxxxxx.RPT.EDPS_005_DSPSUM_ File RPTxxxxx.RPT.EDPS_006_EDTDSP_ File RPTxxxxx.RPT.EDPS_007_DSTDTL_ File 837 Institutional Companion Guide Version 38.0/July 2016 . 23 TABLE 8 – PRODUCTION EDFES REPORTS FILE NAMING CONVENTIONS 1. File Name Record 3. File Count Record REPORT TYPE GENTRAN/TIBCO MAILBOX FTP MAILBOX EDFES Notifications P.xxxxx.EDS_RESPONSE.pn RSPxxxxx.RSP.REJECTED_ID TA1 P.xxxxx.EDS_REJT_IC_ISAIEA.pn X12xxxxx.X12.TMMDDCCYYHHMMS 999 P.xxxxx.EDS_REJT_FUNCT_TRANS.pn 999#####.999.999 999 P.xxxxx.EDS_ACCPT_FUNCT_TRANS.pn 999#####.999.999 277CA P.xxxxx.EDS_RESP_CLAIM_NUM.pn RSPxxxxx.RSP_277CA Table 9 below provides the production EDPS reports file naming conventions per connectivity method. TABLE 9 – PRODUCTION EDPS REPORTS FILE NAMING CONVENTIONS 6.7 EDFES Notifications The EDFES distributes special notifications to submitters when encounters have been processed by the EDFES, but will not proceed to the EDPS for further processing. These notifications are distributed to MAOs and other entities, in addition to standard EDFES Acknowledgement Reports (TA1, 999, and 277CA) in order to avoid returned, unprocessed files from the EDS. Table 10 provides the file type, EDFES notification message, and EDFES notification message description. The file has an 80 character record length and contains the following record layout: a. Positions 1 – 7 = Blank Spaces b. Positions 8 – 18 = File Name: c. Positions 19 – 62 = Name of the Saved File d. Positions 63 – 80 = Blank Spaces 2. File Control Record a. Positions 1 – 4 = Blank Spaces b. Positions 5 – 18 = File	Jul2016_CG_837I_5CR_081016.pdf
X12xxxxx.X12.TMMDDCCYYHHMMS 999 T.xxxxx.EDS_REJT_FUNCT_TRANS.pn 999#####.999.999 999 T.xxxxx.EDS_ACCPT_FUNCT_TRANS.pn 999#####.999.999 277CA T.xxxxx.EDS_RESP_CLAIM_NUM.pn RSPxxxxx.RSP_277CA Table 6 below provides the EDPS reports file naming conventions by connectivity method. MAOs and other entities should note that Connect:Direct (NDM) users’ reports file naming conventions are user defined. TABLE 6 – TESTING EDPS REPORTS FILE NAMING CONVENTIONS Table 7 below provides a description of the file name components, which will assist MAOs and other entities in identifying the report types. TABLE 7 – FILE NAME COMPONENT DESCRIPTION FILE NAME COMPONENT DESCRIPTION RSPxxxxx The type of data ‘RSP’ and a sequential number assigned by the server ‘xxxxx’ X12xxxxx The type of data ‘X12’ and a sequential number assigned by the server ‘xxxxx’ TMMDDCCYYHHMMS The Date and Time stamp the file was processed 999xxxxx The type of data ‘999’ and a sequential number assigned by the server ‘xxxxx’ RPTxxxxx The type of data ‘RPT’ and a sequential number assigned by the server ‘xxxxx’ EDPS_XXX Identifies the specific EDPS Report along with the report number (i.e., ‘002’, etc.) XXXXXXX Seven (7) characters available to be used as a short description of the contents of the file RPT/FILE Identifies if the file is a formatted report ‘RPT’ or a flat file ‘FILE’ layout 6.6.2 Production Reports File Naming Convention A different production reports file naming convention is used so that MAOs and other entities may easily identify reports generated and distributed during production. Table 8 below provides the reports file naming conventions per connectivity method for production reports. CONNECTIVITY METHOD TESTING NAMING CONVENTION FORMATTED REPORT TESTING NAMING CONVENTION FLAT FILE LAYOUT GENTRAN/ TIBCO T .xxxxx.EDPS_001_DataDuplicate_Rpt T.xxxxx.EDPS_002_DataProcessingStatus_Rpt T .xxxxx.EDPS_004_RiskFilter_Rpt T.xxxxx.EDPS_005_DispositionSummary_Rpt T .xxxxx.EDPS_006_EditDisposition_Rpt T .xxxxx.EDPS_007_DispositionDetail_Rpt T .xxxxx.EDPS_001_DataDuplicate_File T.xxxxx.EDPS_002_DataProcessingStatus_File T .xxxxx.EDPS_004_RiskFilter_File T.xxxxx.EDPS_005_DispositionSummary_ File T .xxxxx.EDPS_006_EditDisposition_ File T .xxxxx.EDPS_007_DispositionDetail_ File FTP RPTxxxxx.RPT.EDPS_001_DATDUP_RPT RPTxxxxx.RPT.EDPS_002_DATPRS_RPT RPTxxxxx.RPT.EDPS_004_RSKFLT_RPT RPTxxxxx.RPT.EDPS_005_DSPSUM_RPT RPTxxxxx.RPT.EDPS_006_EDTDSP_RPT RPTxxxxx.RPT.EDPS_007_DSTDTL_RPT RPTxxxxx.RPT.EDPS_001_DATDUP_File RPTxxxxx.RPT.EDPS_002_DATPRS_File RPTxxxxx.RPT.EDPS_004_RSKFLT_ File RPTxxxxx.RPT.EDPS_005_DSPSUM_ File RPTxxxxx.RPT.EDPS_006_EDTDSP_ File RPTxxxxx.RPT.EDPS_007_DSTDTL_ File 837 Institutional Companion Guide Version 38.0/July 2016 . 23 TABLE 8 – PRODUCTION EDFES REPORTS FILE NAMING CONVENTIONS 1. File Name Record 3. File Count Record REPORT TYPE GENTRAN/TIBCO MAILBOX FTP MAILBOX EDFES Notifications P.xxxxx.EDS_RESPONSE.pn RSPxxxxx.RSP.REJECTED_ID TA1 P.xxxxx.EDS_REJT_IC_ISAIEA.pn X12xxxxx.X12.TMMDDCCYYHHMMS 999 P.xxxxx.EDS_REJT_FUNCT_TRANS.pn 999#####.999.999 999 P.xxxxx.EDS_ACCPT_FUNCT_TRANS.pn 999#####.999.999 277CA P.xxxxx.EDS_RESP_CLAIM_NUM.pn RSPxxxxx.RSP_277CA Table 9 below provides the production EDPS reports file naming conventions per connectivity method. TABLE 9 – PRODUCTION EDPS REPORTS FILE NAMING CONVENTIONS 6.7 EDFES Notifications The EDFES distributes special notifications to submitters when encounters have been processed by the EDFES, but will not proceed to the EDPS for further processing. These notifications are distributed to MAOs and other entities, in addition to standard EDFES Acknowledgement Reports (TA1, 999, and 277CA) in order to avoid returned, unprocessed files from the EDS. Table 10 provides the file type, EDFES notification message, and EDFES notification message description. The file has an 80 character record length and contains the following record layout: a. Positions 1 – 7 = Blank Spaces b. Positions 8 – 18 = File Name: c. Positions 19 – 62 = Name of the Saved File d. Positions 63 – 80 = Blank Spaces 2. File Control Record a. Positions 1 – 4 = Blank Spaces b. Positions 5 – 18 = File Control: c. Positions 19 – 27 = File Control Number d. Positions 28 – 80 = Blank Spaces a. Positions 1 – 18 = Number of Claims: CONNECTIVITY METHOD PRODUCTION NAMING CONVENTION FORMATTED REPORT PRODUCTION NAMING CONVENTION FLAT FILE LAYOUT GENTRAN/ TIBCO P.xxxxx.EDPS_001_DataDuplicate_Rpt P.xxxxx.EDPS_002_DataProcessingStatus_Rpt P.xxxxx.EDPS_004_RiskFilter_Rpt P.xxxxx.EDPS_005_DispositionSummary_Rpt P.xxxxx.EDPS_006_EditDisposition_Rpt P.xxxxx.EDPS_007_DispositionDetail_Rpt P.xxxxx.EDPS_001_DataDuplicate_File P.xxxxx.EDPS_002_DataProcessingStatus_File P.xxxxx.EDPS_004_RiskFilter_File P.xxxxx.EDPS_005_DispositionSummary_ File P.xxxxx.EDPS_006_EditDisposition_ File P.xxxxx.EDPS_007_DispositionDetail_ File FTP RPTxxxxx.RPT.PROD_001_DATDUP_RPT RPTxxxxx.RPT.PROD_002_DATPRS_RPT RPTxxxxx.RPT.PROD_004_RSKFLT_RPT RPTxxxxx.RPT.PROD_005_DSPSUM_RPT RPTxxxxx.RPT.PROD_006_EDTDSP_RPT RPTxxxxx.RPT.PROD_007_DSTDTL_RPT RPTxxxxx.RPT.PROD_001_DATDUP_File RPTxxxxx.RPT.PROD_002_DATPRS_File RPTxxxxx.RPT.PROD_004_RSKFLT_ File RPTxxxxx.RPT.PROD_005_DSPSUM_ File RPTxxxxx.RPT.PROD_006_EDTDSP_ File RPTxxxxx.RPT.PROD_007_DSTDTL_ File 837 Institutional Companion Guide Version 38.0/July 2016 . 24 b. Positions 19 – 24 = File Claim Count c. Positions 25 – 80 = Blank Spaces 4. File Separator Record a. Positions 1 – 80 = Separator (----------) 5. File Message Record a. Positions 1 – 80 = FILE WAS NOT SENT TO THE EDPS BACK-END PROCESS FOR THE FOLLOWING REASON(S) 6. File Message Records a. Positions 1 – 80 = File Message The report format example is as follows: FILE NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX FILE CONTROL: XXXXXXXXX NUMBER OF CLAIMS: 99,999 FILE WAS NOT SENT TO THE EDPS BACK-END PROCESS FOR THE FOLLOWING REASON(S) XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Table 10 provides the complete list of testing and production EDFES notification messages. TABLE 10 – EDFES NOTIFICATIONS APPLIES TO NOTIFICATION MESSAGE NOTIFICATION MESSAGE DESCRIPTION All files submitted FILE ID (XXXXXXXXX) IS A DUPLICATE OF A FILE ID SENT WITHIN THE LAST 12 MONTHS The file ID must be unique for a 12 month period All files submitted SUBMITTER NOT AUTHORIZED TO SEND CLAIMS FOR PLAN (CONTRACT ID) The submitter is not authorized to send for this plan All files submitted PLAN ID CANNOT BE THE SAME AS THE SUBMITTER ID The Contract ID cannot be the same as the Submitter ID All files submitted AT LEAST ONE ENCOUNTER IS MISSING A CONTRACT ID IN THE 2010BB-REF02 SEGMENT The Contract ID is missing Production files submitted SUBMITTER NOT CERTIFIED FOR PRODUCTION The submitter must be certified to send encounters for production Tier 2 files submitted THE INTERCHANGE USAGE INDICATOR MUST EQUAL ‘T’ The Institutional Tier 2 file is being sent with a ‘P’ in the ISA15 field Tier 2 files submitted PLAN (CONTRACT ID) HAS (X,XXX) CLAIMS IN THIS FILE. ONLY 2,000 ARE ALLOWED The number of encounters for a Contract ID cannot be greater than 2,000 End-to-End Testing FILE CANNOT CONTAIN MORE THAN 6 ENCOUNTERS The number of encounters cannot be greater than 6 End-to-End Testing PATIENT CONTROL NUMBER IS MORE THAN 20 CHARACTERS LONG THE TC# WAS TRUNCATED The Claim Control Number, including the Test Case Number, must not exceed 20 characters End-to-End Testing FILE CONTAINS (X) TEST CASE (X) ENCOUNTER(S) The file must contain two (2) of each test case Test NO TEST CASES FOUND IN THIS FILE This file was processed with the Interchange Usage Indicator = ‘T’ and the Submitter is not yet Certified 837 Institutional Companion Guide Version 38.0/July 2016 . 25 APPLIES TO NOTIFICATION MESSAGE NOTIFICATION MESSAGE DESCRIPTION End-to-End Testing ADDITIONAL FILES CANNOT BE VALIDATED UNTIL AN MAO-002 REPORT HAS BEEN RECEIVED The MAO-002 report must be received before additional files can be submitted All files submitted FILE CANNOT EXCEED 5,000 ENCOUNTERS The maximum number of encounters allowed in a file All files submitted TRANSACTION SET (ST/SE) (XXXXXXXXX) CANNOT EXCEED 5,000 CLAIMS There can only be 5,000 claims in each ST/SE Loop All files submitted DATE OF SERVICE CANNOT BE BEFORE 2011 Files cannot be submitted with a date of service before 2011 All files submitted CAS ADJUSTMENT AMOUNT MUST NOT BE 0 The CAS Adjustment Amount cannot be zero (0). All files submitted BILLING PROVIDER LOOP IS MISSING The Billing Provider Loop must be present. 7.0 Front-End Edits CMS provides a list of the edits used to process all encounters submitted to the EDFES. The CMS 5010 Institutional Edits Spreadsheet identifies currently active and deactivated edits for MAOs and other entities to reference for programming their internal systems and reconciling EDFES Acknowledgement Reports. The CMS 5010 Institutional Edits Spreadsheet provides documentation regarding edit rules that explain how to identify an EDFES edit and the associated logic. The CMS 5010 Institutional Edits Spreadsheet also provides a change log that lists the revision history for edit updates. MAOs and other entities are able to access the CMS 5010 Institutional Edits Spreadsheet on the CMS website at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/ 1. Select the current year in the left navigation column (e.g., 2015 Transmittals) 2. Key in 'EDI Front End Updates' in the 'Filter On' box 3. Select the most current transmittal to obtain the latest versions of the CEM Edits Spreadsheets 4. Click on the link(s) under 'Downloads' at the bottom of the page 7.1 Deactivated Front-End Edits Several CEM edits currently active in the CMS 5010 Institutional Edits Spreadsheet will be deactivated in order to ensure that syntactically correct encounters pass front-edit editing. Table 11 provides a list of the deactivated EDFES CEM edits. The edit reference column provides the exact reference for the deactivated edits. The edit description column provides the Claim Status Category Code (CSCC), the Claim Status Code (CSC), and the Entity Identifier Code (EIC), when applicable. The notes column provides a description of the edit reason. MAOs and other entities should reference the WPC website at www.wpc-edi.com for a complete listing of all CSCCs and CSCs. 837 Institutional Companion Guide Version 38.0/July 2016 . 26 TABLE 11 – 837 INSTITUTIONAL DEACTIVATED EDFES EDITS EDIT REFERENCE EDIT DESCRIPTION EDIT NOTES X223.084.2010AA.NM109.050 CSCC A8: "Acknowledgement / Rejected for relational field in error" CSC 496 "Submitter not approved for electronic claim submissions on behalf of this entity." EIC: 85 Billing Provider This Fee for Service edit validates the NPI and submitter ID number to ensure the submitter is authorized to submit on the provider’s behalf. Encounter data cannot use this validation as we validate the plan number and submitter ID to ensure the submitter is authorized to submit on the plan’s behalf. 2010AA.NM109 billing provider must be "associated" to the submitter (from a trading partner management perspective) in 1000A.NM109. X223.087.2010AA.N301.070 CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 503: "Entity's Street Address" EIC: 85 Billing Provider Remove edit check for 2010AA N3 PO Box variations when ISA08 = 80881 (Institutional Payer Code). X223.084.2010AA.NM109.040 CSCC A8: "Acknowledgement / Rejected for relational field in error." CSC 562: "Entity's National Provider Identifier (NPI)" EIC: 85 Billing Provider Valid NPI Crosswalk must be available for this edit. 2010AA.NM109 must be a valid NPI on the Crosswalk when evaluated with 1000B.NM109. X223.090.2010AA.REF02.050 CSCC A8: "Acknowledgement / Rejected for relational field in error" CSC 562: "Entity's National Provider Identifier (NPI)" CSC 128: "Entity's tax id" EIC: 85 Billing Provider Valid NPI Crosswalk must be available for this edit. 2010AA.REF must be associated with the provider identified in 2010AA.NM109. X223.127.2010BB.REF.010 CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 732: "Information submitted inconsistent with billing guidelines." CSC 560: "Entity's Additional/Secondary Identifier." EIC: PR "Payer" This REF Segment is used to capture the Plan number as this is unique to encounter data submission only. The CEM applies the following logic: Non-VA claims: 2010BB.REF with REF01 = "2U", "EI", "FY" or "NF" must not be present. VA claims: 2010BB.REF with REF01 = "EI", "FY" or "NF" must not be present. This edit needs to remain off in order for the submitter to send in his plan number. X223.424.2400.SV202-7.025 CSCC A8: "Acknowledgement / Rejected for relational field in error" CSC 306 Detailed description of service 2400.SV202-7 must be present when 2400.SV202-2 contains a non-specific procedure code. When using a not otherwise classified or generic HCPCS procedure code the CEM is editing for a more descriptive meaning of the procedure code. For example, the submitter is using J3490. The description for this HCPCS is Not Otherwise Classified (NOC) Code. 837 Institutional Companion Guide Version 38.0/July 2016 . 27 EDIT REFERENCE EDIT DESCRIPTION EDIT NOTES X223.153.2300.CL103.015 CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 234: "Patient discharge status" When 2300.CL103 value “20”, “40”, “41”, or “42” is present, at least one occurrence of 2300.HI01-2 thru HI12-2 must = “55” where HI01-1 is “BH”. X223.424.2400.SV203.060 CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 400: "Claim is out of balance: CSC 583:"Line Item Charge Amount" CSC 643: "Service Line Paid Amount" SV203 must = the sum of all payer amounts paid found in 2430 SVD02 and the sum of all line adjustments found in 2430 CAS Adjustment Amounts. X223.143.2300.CLM02.070 CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 400: "Claim is out of balance" CSC 178: "Submitted Charges" 2300.CLM02 must = the sum of all 2400.SV203 amounts. X223.143.2300.CLM02.080 CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 400: "Claim is out of Balance" CSC 672 "Payer's payment information is out of balance CLM02 must equal the sum of all 2320 CAS amounts and all 2430 CAS amounts and 2320 AMT02 (when AMT01=D). X223.389.2330B.DTP.030 IK304 = 2: "Unexpected Segment" If 2430 DTP with 573 is present, then 2330B DTP must not be present. 837 Institutional Companion Guide Version 38.0/July 2016 . 28 7.2 Temporarily Deactivated Front-End Edits Table 12 provides a list of the temporarily deactivated EDFES Institutional CEM balancing edits in order to ensure that encounters that require balancing of monetary fields will pass front-end editing. Note: The Institutional edits listed in Table 12 are not all-inclusive and are subject	Jul2016_CG_837I_5CR_081016.pdf
Code). X223.084.2010AA.NM109.040 CSCC A8: "Acknowledgement / Rejected for relational field in error." CSC 562: "Entity's National Provider Identifier (NPI)" EIC: 85 Billing Provider Valid NPI Crosswalk must be available for this edit. 2010AA.NM109 must be a valid NPI on the Crosswalk when evaluated with 1000B.NM109. X223.090.2010AA.REF02.050 CSCC A8: "Acknowledgement / Rejected for relational field in error" CSC 562: "Entity's National Provider Identifier (NPI)" CSC 128: "Entity's tax id" EIC: 85 Billing Provider Valid NPI Crosswalk must be available for this edit. 2010AA.REF must be associated with the provider identified in 2010AA.NM109. X223.127.2010BB.REF.010 CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 732: "Information submitted inconsistent with billing guidelines." CSC 560: "Entity's Additional/Secondary Identifier." EIC: PR "Payer" This REF Segment is used to capture the Plan number as this is unique to encounter data submission only. The CEM applies the following logic: Non-VA claims: 2010BB.REF with REF01 = "2U", "EI", "FY" or "NF" must not be present. VA claims: 2010BB.REF with REF01 = "EI", "FY" or "NF" must not be present. This edit needs to remain off in order for the submitter to send in his plan number. X223.424.2400.SV202-7.025 CSCC A8: "Acknowledgement / Rejected for relational field in error" CSC 306 Detailed description of service 2400.SV202-7 must be present when 2400.SV202-2 contains a non-specific procedure code. When using a not otherwise classified or generic HCPCS procedure code the CEM is editing for a more descriptive meaning of the procedure code. For example, the submitter is using J3490. The description for this HCPCS is Not Otherwise Classified (NOC) Code. 837 Institutional Companion Guide Version 38.0/July 2016 . 27 EDIT REFERENCE EDIT DESCRIPTION EDIT NOTES X223.153.2300.CL103.015 CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 234: "Patient discharge status" When 2300.CL103 value “20”, “40”, “41”, or “42” is present, at least one occurrence of 2300.HI01-2 thru HI12-2 must = “55” where HI01-1 is “BH”. X223.424.2400.SV203.060 CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 400: "Claim is out of balance: CSC 583:"Line Item Charge Amount" CSC 643: "Service Line Paid Amount" SV203 must = the sum of all payer amounts paid found in 2430 SVD02 and the sum of all line adjustments found in 2430 CAS Adjustment Amounts. X223.143.2300.CLM02.070 CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 400: "Claim is out of balance" CSC 178: "Submitted Charges" 2300.CLM02 must = the sum of all 2400.SV203 amounts. X223.143.2300.CLM02.080 CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 400: "Claim is out of Balance" CSC 672 "Payer's payment information is out of balance CLM02 must equal the sum of all 2320 CAS amounts and all 2430 CAS amounts and 2320 AMT02 (when AMT01=D). X223.389.2330B.DTP.030 IK304 = 2: "Unexpected Segment" If 2430 DTP with 573 is present, then 2330B DTP must not be present. 837 Institutional Companion Guide Version 38.0/July 2016 . 28 7.2 Temporarily Deactivated Front-End Edits Table 12 provides a list of the temporarily deactivated EDFES Institutional CEM balancing edits in order to ensure that encounters that require balancing of monetary fields will pass front-end editing. Note: The Institutional edits listed in Table 12 are not all-inclusive and are subject to amendment. TABLE 12 – 837 INSTITUTIONAL TEMPORARILY DEACTIVATED EDFES EDITS EDIT REFERENCE EDIT DESCRIPTION EDIT NOTES X223.364.2320.AMT.040 CSCC A7: Acknowledgement/Rejected for Invalid Information CSC 41: Special handling required at payer site CSC 286: Other Payer's Explanation of Benefits/payment information CSC 732: Information submitted inconsistent with billing guidelines N/A X223.109.2000B.SBR03.004 X223.109.2000B.SBR03.006 CSCC A8: Acknowledgement/ Rejected for relational field in error CSC 163: Entity’s Policy Number CSC 732: Information submitted inconsistent with billing guidelines EIC IL: Subscriber N/A X223.109.2000B.SBR04.004 X223.109.2000B.SBR04.007 CSCC A8: Acknowledgement/Rejected for relational field in error CSC 663: Entity's Group Name CSC 732: Information submitted inconsistent with billing guidelines EIC IL: Subscriber N/A 7.3 New EDFES Edits Table 13 provides a list of EDFES Institutional CEM edits recently added or revised that may impact encounter processing. TABLE 13 – 837 NEW INSTITUTIONAL EDFES EDITS Note: Table 13 will not be provided when there are no relevant enhancements implemented for the current release of the CMS EDS Companion Guides. 8.0 Duplicate Logic In order to ensure encounters submitted are not duplicates of encounters previously submitted, the EDS will perform header and detail level duplicate checking. If the header and/or detail level duplicate checking determines that the file is a duplicate, the file will reject, and an error report will be returned to the submitter. 837 Institutional Companion Guide Version 38.0/July 2016 . 29 8.1 Header Level When a file (ISA/IEA) is received, the system assigns a hash total to the file based on the entire ISA/IEA interchange. The EDS uses hash totals to ensure the accuracy of processed data. The hash total is a total of several fields or data in a file, including fields not normally used in calculations, such as the account number. At various stages in processing, the hash total is recalculated and compared with the original. If a file comes in later in a different submission, or a different submission of the same file, and gets the same hash total, it will reject as a duplicate. In addition to the hash total, the system also references the values collectively populated in ISA13, GS06, ST02, and BHT03. If two (2) files are submitted with the exact same values populated as a previously submitted and accepted file, the file will be considered a duplicate and the error message CSCC - A8 = Acknowledgement / Rejected for relational field in error, CSC -746 = Duplicate Submission will be provided on the 277CA. 8.2 Detail Level Once an encounter is processed in the EDPS, it is stored in an internal repository, the Encounter Operational Data Store (EODS). If a new encounter is submitted that matches specific values on another stored encounter, the encounter will reject as a duplicate encounter. The encounter will be returned to the submitter with an error message identifying it as a duplicate encounter. Currently, the following values are the minimum set of items used for matching an encounter in the EODS: • Beneficiary Demographic o Health Insurance Claim Number (HICN) • Date of Service • Type of Bill (TOB) • Revenue Code(s) • Procedure Code(s) and up to 4 modifiers • Billing Provider NPI • Charge (Billed) Amount • Paid Amount (as populated at both the Header and Detail Levels)* * Paid Amounts by the MAO and other entity will only be used in the duplicate validation logic. 9.0 837 Institutional Business Cases In accordance with 45 CFR 160.103 of the HIPAA, Protected Health Information (PHI) is not included in the 837-I business cases. As a result, the business cases have been populated with fictitious information about the Subscriber, MAO, and provider(s). The business cases reflect 2012 dates of service. Although the business cases are provided as examples of possible encounter submissions, MAOs and other entities must populate valid data in order to successfully pass translator and CEM level editing. MAOs and other entities should direct questions regarding the contents of the EDS Test Case Specification to [email protected]. Note: The business cases identified in the CMS EDS 837-I Companion Guide indicate paid amounts and DTP segments at the line level. 837 Institutional Companion Guide Version 38.0/July 2016 . 30 The Adjudication or Payment Date (DTP 573 segment) must follow the paid amount. For example, if the paid amount is populated at the claim level, the DTP 573 segment must be populated at the claim level. If the paid amount is populated at the line level, the DTP 573 segment must be populated at the line level. 837 Institutional Companion Guide Version 38.0/July 2016 . 31 9.1 Standard Institutional Encounter Business Scenario 1: Patient/subscriber, Mary Dough, was admitted into Mercy Hospital complaining of heart pain. Happy Health Plan was the MAO. Mercy Hospital diagnosed Mary with Congestive Health Failure as the primary diagnosis and diabetes as an additional diagnosis. File String 1: ISA00 00 ZZENH9999 ZZ80881 120816114 4^005010000000311P:~ GSHCENH99998088120120816114431X005010X223A2~ ST8370034005010X223A2~ BHT0019003920394930203201208141615CH~ NM1412HAPPY HEALTH PLAN****46ENH9999~ PERICMICAH THOMASTE5555552222~ NM1402EDSCMS***4680881~ HL1201~ NM1852MERCY HOSPITAL***XX1299999999~ N3876 MERCY DRIVE~ N4NORFOLKVA235089999~ REFEI344232321~ PERICELIZABETH SMITHTE9195551111~ HL21220~ SBRS18XYZ1234567****MA~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ DMGD819390807F~ NM1PR2EDSCMS****PI80881~ N37500 SECURITY BLVD~ N4BALTIMOREMD212441850 REF2UH9999~ CLM22350578967509876984536578798A200.00*11:A:1AYY~ DTP096TM0958~ DTP434RD820120330-20120331~ DTP435D820120330~ CL12901~ HIBK:4280~ HIBJ:4280~ HIBF:25000~ HIBR:3121:D8:20120330~ HIBH:41:D8:20110501BH:27:D8:20110715BH:33:D8:20110718BH:C2:D8:20110729~ HIBE:30:::20~ HIBG:01~ NM1711JONESAMANDAAL*XX1005554104~ 837 Institutional Companion Guide Version 38.0/July 2016 . 32 SBRP18XYZ1234567****16~ AMTD200.00~ OIYY~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ NM1PR2HAPPY HEALTH PLAN***XVH9999~ N3705 E HUGH ST~ N4NORFOLKVA235049999~ REFT4Y~ LX1~ SV20300HC:81099200.00UN1~ DTP472D820120330~ SVDH9999200.00HC:8109903001~ DTP573D820120401~ SE500034~ GE131~ IEA1000000031~ 837 Institutional Companion Guide Version 38.0/July 2016 . 33 9.2 Capitated Institutional Encounter Business Scenario 2: Patient/subscriber, Mary Dough, is enrolled in Happy Health Plan and went to Mercy Hospital because she was experiencing leg pain. Mercy Hospital diagnosed Mary with diabetes and leg pain. Happy Health Plan has a capitated arrangement with Mercy Hospital. Note: For Institutional EDRs, the indicator of whether a record is capitated occurs at the header level. In the event that the MAO has a contractual arrangement with a provider under which certain services are paid on a FFS basis and other services are paid on capitated basis, the MAO should submit as a single EDR with the CN101(Contract Type Code) at the header level in LOOP 2300 left blank and populate the CAS segment at the line level within LOOP 2430 with a Group Reason Code of 24 to indicate a capitated service line. For FFS lines, the Group Reason Code should be populated using the codes submitted by the provider on the 835. If all lines in an institutional EDR are capitated, then the EDR should be submitted with the CN101(Contract Type Code) at the header level in LOOP 2300 set to ‘05’. File String 2: ISA00* 00 ZZENH9999 ZZ80881 120816114 4^005010000003311P:~ GSHCENH99998088120120816114430X005010X223A2~ ST8370021005010X223A2~ BHT0019003920394930203201208141615CH~ NM1412HAPPY HEALTH PLAN****46ENH9999~ PERICMICAH THOMASTE5555552222~ NM1402EDSCMS***4680881~ HL1201~ NM1852MERCY HOSPITAL***XX1299999999~ N3876 MERCY DRIVE~ N4NORFOLKVA235089999~ REFEI344232321~ PERICELIZABETH SMITHTE9195551111~ HL21220~ SBRS18XYZ1234567****MA~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ DMGD819390807F~ NM1PR2EDSCMS****PI80881~ N37500 SECURITY BLVD~ N4BALTIMOREMD212441850 REF2UH9999~ CLM22350578967509876984536578798A 0.00*11:A:1AYY~ 837 Institutional Companion Guide Version 38.0/July 2016 . 34 DTP096TM0958~ DTP434RD820120330-20120331~ DTP435D820120330~ CL12901~ CN105~ HIBK:4280~ HIBJ:4280~ HIBF:25000~ HIBR:3121:D8:20120330~ HIBH:41:D8:20110501BH:27:D8:20110715BH:33:D8:20110718BH:C2:D8:20110729~ HIBE:30:::20~ HIBG:01~ NM1711JONESAMANDAAL**XX1005554104~ SBRP18XYZ1234567****ZZ~ AMTD100.50~ OIYY~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ NM1PR2HAPPY HEALTH PLAN***XVH9999~ N3705 E HUGH ST~ N4NORFOLKVA235049999~ LX1~ SV20300HC:810990.00UN1~ DTP472D820120330~ SVDH9999100.50HC:8109903001~ CASCO24-100.50~ DTP573D820120401~ SE500021~ GE130~ IEA1000000331~ 837 Institutional Companion Guide Version 38.0/July 2016 . 35 9.3 Chart Review Institutional Encounter – No Linked ICN Business Scenario 3: Patient/subscriber, Mary Dough, went to Mercy Hospital because she was experiencing leg pain. Happy Health Plan was the MAO. Happy Health Plan performs a chart review at Mercy Hospital and determines that a diagnosis for Mary Dough was never submitted on a claim. The medical record does not contain enough information to submit a full claim, yet there is enough information to support the diagnosis and link the chart review encounter back to the medical record. Happy Health Plan submits a chart review encounter with no linked ICN to add the diagnosis. File String 3: ISA00 00 ZZENH9999 ZZ80881 120816114 4^005010000000311P:~ GSHCENH99998088120120816114431X005010X223A2~ ST8370034005010X223A2~ BHT0019003920394930203201208141615CH~ NM1412HAPPY HEALTH PLAN****46ENH9999~ PERICMICAH THOMASTE5555552222~ NM1402EDSCMS***4680881~ HL1201~ NM1852MERCY HOSPITAL***XX1299999899~ N3876 MERCY DRIVE~ N4NORFOLKVA235089999~ REFEI344232321~ PERICELIZABETH SMITHTE9195551111~ HL21220~ SBRS18XYZ1234567****MA~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ DMGD819390807F~ NM1PR2EDSCMS****PI80881~ N37500 SECURITY BLVD~ N4BALTIMOREMD212441850 REF2UH9999~ CLM22350578967509876984536578798A0.00*11:A:1AYY~ DTP096TM0958~ DTP434RD820120330-20120331~ DTP435D820120330~ CL12901~ PWK09AA~ HIBK:4280~ HIBJ:4280~ HIBF:25000~ HIBR:3121:D8:20120330~ HIBH:41:D8:20110501BH:27:D8:20110715BH:33:D8:20110718BH:C2:D8:20110729~ 837 Institutional Companion Guide Version 38.0/July 2016 . 36 HIBE:30:::20~ HIBG:01~ NM1711JONESAMANDAAL*XX1005554104~ SBRP18XYZ1234567****16~ AMTD0.00~ OIYY~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ NM1PR2HAPPY HEALTH PLAN***XVH9999~ N3705 E HUGH ST~ N4NORFOLKVA235049999~ REFT4Y~ LX1~ SV20300HC:810990.00UN1~ SVDH999965.00HC:810991~ DTP472D820120330~ SE490034~ GE131~ IEA1000000031~ 837 Institutional Companion Guide Version 38.0/July 2016 . 37 9.4 Chart Review Institutional Encounter – Linked ICN (Add Diagnoses) Business Scenario 4: Patient/subscriber, Mary Dough, went to Mercy Hospital because she was experiencing leg pain. Happy Health Plan was the MAO. Mercy Hospital submits the encounter to CMS and receives an ICN of 1294598098746. Happy Health Plan performs a chart review related to ICN 1294598098746 and determines that additional diagnoses were not originally reported for diabetes and high cholesterol. Note: In the event that a linked chart review encounter requires the addition and deletion of multiple diagnosis codes, MAOs should submit a single linked chart review encounter (2300 CLM05-3 = ‘1’(Original)) to add all necessary diagnoses, and submit a separate linked chart review encounter (also 2300 CLM05-3 = ‘1’(Original)) to delete all necessary diagnosis codes. MAOs should submit a replacement chart review encounter (2300 CLM05-3 = ‘7’) only in the event previously stored chart review data should be completely replaced. MAOs should	Jul2016_CG_837I_5CR_081016.pdf
24 to indicate a capitated service line. For FFS lines, the Group Reason Code should be populated using the codes submitted by the provider on the 835. If all lines in an institutional EDR are capitated, then the EDR should be submitted with the CN101(Contract Type Code) at the header level in LOOP 2300 set to ‘05’. File String 2: ISA00 00 ZZENH9999 ZZ80881 120816114 4^005010000003311P:~ GSHCENH99998088120120816114430X005010X223A2~ ST8370021005010X223A2~ BHT0019003920394930203201208141615CH~ NM1412HAPPY HEALTH PLAN****46ENH9999~ PERICMICAH THOMASTE5555552222~ NM1402EDSCMS***4680881~ HL1201~ NM1852MERCY HOSPITAL***XX1299999999~ N3876 MERCY DRIVE~ N4NORFOLKVA235089999~ REFEI344232321~ PERICELIZABETH SMITHTE9195551111~ HL21220~ SBRS18XYZ1234567****MA~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ DMGD819390807F~ NM1PR2EDSCMS****PI80881~ N37500 SECURITY BLVD~ N4BALTIMOREMD212441850 REF2UH9999~ CLM22350578967509876984536578798A 0.00*11:A:1AYY~ 837 Institutional Companion Guide Version 38.0/July 2016 . 34 DTP096TM0958~ DTP434RD820120330-20120331~ DTP435D820120330~ CL12901~ CN105~ HIBK:4280~ HIBJ:4280~ HIBF:25000~ HIBR:3121:D8:20120330~ HIBH:41:D8:20110501BH:27:D8:20110715BH:33:D8:20110718BH:C2:D8:20110729~ HIBE:30:::20~ HIBG:01~ NM1711JONESAMANDAAL**XX1005554104~ SBRP18XYZ1234567****ZZ~ AMTD100.50~ OIYY~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ NM1PR2HAPPY HEALTH PLAN***XVH9999~ N3705 E HUGH ST~ N4NORFOLKVA235049999~ LX1~ SV20300HC:810990.00UN1~ DTP472D820120330~ SVDH9999100.50HC:8109903001~ CASCO24-100.50~ DTP573D820120401~ SE500021~ GE130~ IEA1000000331~ 837 Institutional Companion Guide Version 38.0/July 2016 . 35 9.3 Chart Review Institutional Encounter – No Linked ICN Business Scenario 3: Patient/subscriber, Mary Dough, went to Mercy Hospital because she was experiencing leg pain. Happy Health Plan was the MAO. Happy Health Plan performs a chart review at Mercy Hospital and determines that a diagnosis for Mary Dough was never submitted on a claim. The medical record does not contain enough information to submit a full claim, yet there is enough information to support the diagnosis and link the chart review encounter back to the medical record. Happy Health Plan submits a chart review encounter with no linked ICN to add the diagnosis. File String 3: ISA00 00 ZZENH9999 ZZ80881 120816114 4^005010000000311P:~ GSHCENH99998088120120816114431X005010X223A2~ ST8370034005010X223A2~ BHT0019003920394930203201208141615CH~ NM1412HAPPY HEALTH PLAN****46ENH9999~ PERICMICAH THOMASTE5555552222~ NM1402EDSCMS***4680881~ HL1201~ NM1852MERCY HOSPITAL***XX1299999899~ N3876 MERCY DRIVE~ N4NORFOLKVA235089999~ REFEI344232321~ PERICELIZABETH SMITHTE9195551111~ HL21220~ SBRS18XYZ1234567****MA~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ DMGD819390807F~ NM1PR2EDSCMS****PI80881~ N37500 SECURITY BLVD~ N4BALTIMOREMD212441850 REF2UH9999~ CLM22350578967509876984536578798A0.00*11:A:1AYY~ DTP096TM0958~ DTP434RD820120330-20120331~ DTP435D820120330~ CL12901~ PWK09AA~ HIBK:4280~ HIBJ:4280~ HIBF:25000~ HIBR:3121:D8:20120330~ HIBH:41:D8:20110501BH:27:D8:20110715BH:33:D8:20110718BH:C2:D8:20110729~ 837 Institutional Companion Guide Version 38.0/July 2016 . 36 HIBE:30:::20~ HIBG:01~ NM1711JONESAMANDAAL*XX1005554104~ SBRP18XYZ1234567****16~ AMTD0.00~ OIYY~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ NM1PR2HAPPY HEALTH PLAN***XVH9999~ N3705 E HUGH ST~ N4NORFOLKVA235049999~ REFT4Y~ LX1~ SV20300HC:810990.00UN1~ SVDH999965.00HC:810991~ DTP472D820120330~ SE490034~ GE131~ IEA1000000031~ 837 Institutional Companion Guide Version 38.0/July 2016 . 37 9.4 Chart Review Institutional Encounter – Linked ICN (Add Diagnoses) Business Scenario 4: Patient/subscriber, Mary Dough, went to Mercy Hospital because she was experiencing leg pain. Happy Health Plan was the MAO. Mercy Hospital submits the encounter to CMS and receives an ICN of 1294598098746. Happy Health Plan performs a chart review related to ICN 1294598098746 and determines that additional diagnoses were not originally reported for diabetes and high cholesterol. Note: In the event that a linked chart review encounter requires the addition and deletion of multiple diagnosis codes, MAOs should submit a single linked chart review encounter (2300 CLM05-3 = ‘1’(Original)) to add all necessary diagnoses, and submit a separate linked chart review encounter (also 2300 CLM05-3 = ‘1’(Original)) to delete all necessary diagnosis codes. MAOs should submit a replacement chart review encounter (2300 CLM05-3 = ‘7’) only in the event previously stored chart review data should be completely replaced. MAOs should submit a void chart review encounter (2300 CLM05-3 = ‘8’) only when the original chart review encounter (linked or unlinked) requires deletion. File String 4: ISA00 00 ZZENH9999 ZZ80881 120816114 4^005010000000311P:~ GSHCENH99998088120120816114431X005010X223A2~ ST8370034005010X223A2~ BHT0019003920394930203201208141615CH~ NM1412HAPPY HEALTH PLAN****46ENH9999~ PERICMICAH THOMASTE5555552222~ NM1402EDSCMS***4680881~ HL1201~ NM1852MERCY HOSPITAL***XX1299999899~ N3876 MERCY DRIVE~ N4NORFOLKVA235089999~ REFEI344232321~ PERICELIZABETH SMITHTE9195551111~ HL21220~ SBRS18XYZ1234567****MA~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ DMGD819390807F~ NM1PR2EDSCMS****PI80881~ N37500 SECURITY BLVD~ N4BALTIMOREMD212441850 REF2UH9999~ CLM22350578967509876984536578798A0.00*11:A:1AYY~ DTP096TM0958~ 837 Institutional Companion Guide Version 38.0/July 2016 . 38 DTP434RD820120330-20120331~ DTP435D820120330~ CL12901~ PWK09AA~ REFF81294598098746~ HIBK:25000~ (First diagnosis to be added, ‘BK’ – not repeatable) HIBF:2720~ (Second diagnosis to be added, ‘BF’ – repeatable through HI12) NM1711JONESAMANDAAL*XX1005554106~ SBRP18XYZ1234567****16~ AMTD0.00~ OIYY~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ NM1PR2HAPPY HEALTH PLAN***XVH9999~ N3705 E HUGH ST~ N4NORFOLKVA235049999~ REFT4Y~ LX1~ SV20300HC:810990.00UN1~ SVDH999987.50HC:810991~ DTP472D820120330~ SE500034~ GE131~ IEA1000000031~ 837 Institutional Companion Guide Version 38.0/July 2016 . 39 9.5 Chart Review Institutional Encounter – Linked ICN (Delete Diagnoses) Business Scenario 5: Patient/subscriber, Mary Dough, went to Mercy Hospital because she was experiencing leg pain. Happy Health Plan was the MAO. Happy Health Plan submits the encounter to CMS and receives an ICN of 1294598098746. Happy Health Plan performs a chart review related to ICN 1294598098746 and determines that the original encounter should not have reported diagnoses related to diabetes and high cholesterol, which should be deleted. Happy Health Plan submits a Chart Review encounter to delete the relevant diagnoses. Note: In the event that a linked chart review encounter requires the addition and deletion of multiple diagnosis codes, MAOs should submit a single linked chart review encounter (2300 CLM05-03 = ‘1’(Original)) to add all necessary diagnoses, and submit a separate linked chart review encounter (also 2300 CLM05-03 = ‘1’(Original)) to delete all necessary diagnosis codes. MAOs should submit a replacement chart review encounter (2300 CLM05-03 = ‘7’) only in the event previously stored chart review data should be completely replaced. MAOs should submit a void chart review encounter (2300 CLM05-3 = ‘8’) only when the original chart review encounter (linked or unlinked) requires deletion. File String 5: ISA00 00 ZZENH9999 ZZ80881 120816114 4^005010000000311P:~ GSHCENH99998088120120816114431X005010X223A2~ ST8370034005010X223A2~ BHT0019003920394930203201208141615CH~ NM1412HAPPY HEALTH PLAN****46ENH9999~ PERICMICAH THOMASTE5555552222~ NM1402EDSCMS***4680881~ HL1201~ NM1852MERCY HOSPITAL***XX1299999899~ N3876 MERCY DRIVE~ N4NORFOLKVA235089999~ REFEI344232321~ PERICELIZABETH SMITHTE9195551111~ HL21220~ SBRS18XYZ1234567****MA~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ DMGD819390807F~ NM1PR2EDSCMS****PI80881~ N37500 SECURITY BLVD~ N4BALTIMOREMD212441850 REF2UH9999~ CLM22350578967509876984536578798A0.00*11:A:1AYY~ 837 Institutional Companion Guide Version 38.0/July 2016 . 40 DTP096TM0958~ DTP434RD820120330-20120331~ DTP435D820120330~ CL12901~ PWK09AA~ REFF81294598098746~ REFEA8~ HIBK:25000~ (First diagnosis to be deleted, ‘BK’ – not repeatable) HIBF:2720 ~ (Second diagnosis to be deleted, ‘BF’ – repeatable through HI12) NM1711JONESAMANDAAL*XX1005554106~ SBRP18XYZ1234567****16~ AMTD0.00~ OIYY~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ NM1PR2HAPPY HEALTH PLAN***XVH9999~ N3705 E HUGH ST~ N4NORFOLKVA235049999~ REFT4Y~ LX1~ SV20300HC:810990.00UN1~ SVDH999987.50HC:810991~ DTP472D820120330~ SE500034~ GE131~ IEA1000000031~ 837 Institutional Companion Guide Version 38.0/July 2016 . 41 9.6 Complete Replacement Institutional Encounter Business Scenario 6: Patient/subscriber, Mary Dough, went to Mercy Hospital because she was experiencing heart pain. Mercy Hospital diagnosed Mary with Congestive Heart Failure and diabetes. Happy Health Plan submits the encounter to CMS and receives an ICN 1122978564098. After further investigation, it was determined that Happy Health Plan submitted the encounter with an incorrect payment. Happy Health Plan submits a replacement encounter to CMS, using ICN 1122978564098 to correct the payment amount. File String 6: ISA00 00 ZZENH9999 ZZ80881 120816114 4^005010000005541P:~ GSHCENH99998088120120816114480X005010X223A2~ ST8370567005010X223A2~ BHT0019003920394930203201208141615CH~ NM1412HAPPY HEALTH PLAN****46ENH9999~ PERICMICAH THOMASTE5555552222~ NM1402EDSCMS***4680881~ HL1201~ NM1852MERCY HOSPITAL***XX1299999999~ N3876 MERCY DRIVE~ N4NORFOLKVA235089999~ REFEI344232321~ PERICELIZABETH SMITHTE9195551111~ HL21220~ SBRS18XYZ1234567****MA~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ DMGD819390807F~ NM1PR2EDSCMS****PI80881~ N37500 SECURITY BLVD~ N4BALTIMOREMD212441850 REF2UH9999~ CLM22350578967509876984536578798A200.00*11:A:7AYY~ DTP096TM0958 DTP434RD820120330-20120331~ DTP435D820120330-20120331~ CL12901~ REFF81222978564098~ HIBK:4280~ HIBJ:4280~ HIBR:3121:D8:20120330~ HIBH:41:D8:20110501BH:27:D8:20110715BH:33:D8:20110718BH:C2:D8:20110729~ HIBE:30:::20~ 837 Institutional Companion Guide Version 38.0/July 2016 . 42 HIBG:01~ NM1711JOHNSONAMANDAAL**XX1005554104~ SBRP18XYZ1234567****16~ CASCO39120.00~ AMTD80.00~ OI*YY~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ NM1PR2HAPPY HEALTH PLAN***XVH9999~ N3705 E HUGH ST~ N4NORFOLKVA235048769~ LX1~ SV20300HC:81099200.00UN1~ DTP472D820120330~ SVDH99990.00HC:99212*1~ DTP57320120401~ SE500567~ GE180~ IEA1000000554~ 837 Institutional Companion Guide Version 38.0/July 2016 . 43 9.7 Complete Deletion Institutional Encounter Business Scenario 7: Patient/subscriber, Mary Dough, was admitted to Miracle Health Center because she was experiencing abdominal pain. Happy Health Plan is the MAO. Dr. Smart at Miracle Health Center diagnosed Mary with a gastric ulcer. Happy Health Plan submits the encounter to CMS and receives ICN 1212487000032. Happy Health Plan then determines that the claim for Mary’s visit was not adjudicated in their internal system. Happy Health Plan submits a void encounter to delete the previously submitted encounter. File String 7: ISA00* 00 ZZENH9999 ZZ80881 120430114 4^005010000002981P:~ GSHCENH99998088120120430114482X005010X222A1~ ST8370290005010X222A1~ BHT0019003920394930206201204281615CH~ NM1412HAPPY HEALTH PLAN****46ENH9999~ PERICMICAH THOMASTE5555552222~ NM1402EDSCMS***4680881~ HL1201~ NM1851MIRACLE HEALTH CENTER***XX1299999999~ N3123 CENTRAL DRIVE~ N4NORFOLKVA235139999~ REFEI765879876~ PERICELIZABETH SMARTTE9195551111~ HL21220~ SBRS18XYZ123456747**MB~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ DMGD819390807F~ NM1PR2EDSCMS****PI80881~ N37500 SECURITY BLVD~ N4BALTIMOREMD212441850~ REF2UH9999~ CLM2997677856479709654A100.50**11:B:8YAYY~ REFF81212487000032~ HIBK:53190~ SBRP18XYZ1234567****16~ CASCO223100.50~ AMTD0.00~ OI*YY~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ NM1PR2HAPPY HEALTH PLAN***XVH9999~ 837 Institutional Companion Guide Version 38.0/July 2016 . 44 N3705 E HUGH ST~ N4NORFOLKVA235049999~ REFT4Y~ LX1~ SV2HC:99212100.50UN1*1~ DTP472D820120401~ SVDH99990.00HC:992121~ DTP573D820120403~ SE410290~ GE182~ IEA1000000298~ 837 Institutional Companion Guide Version 38.0/July 2016 . 45 9.8 Atypical Provider Institutional Encounter Business Scenario 8: Patient/subscriber, Mary Dough, receives personal care services from an atypical provider. Happy Health Plan was the MAO. File String 8: ISA00 00 ZZENH9999 ZZ80881 120816114 4^005010000000321P:~ GSHCENH99998088120120816114435X005010X223A2~ ST8370039005010X223A2~ BHT0019003920394930203201208141615CH~ NM1412HAPPY HEALTH PLAN****46ENH9999~ PERICMICAH THOMASTE5555552222~ NM1402EDSCMS***4680881~ HL1201~ NM1852MERCY SERVICES***XX1999999976~ N3876 MERCY DRIVE~ N4NORFOLKVA235089999~ REFEI199999997~ PERICELIZABETH SMITHTE9195551111~ HL21220~ SBRS18XYZ1234567****MA~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ DMGD819390807F~ NM1PR2EDSCMS****PI80881~ N37500 SECURITY BLVD~ N4BALTIMOREMD212441850 REF2UH9999~ CLM22350578967509876984536578799A50.00*83:A:1AYY~ DTP434RD820120330-20120331~ CL19901~ HIBK:78099~ NTEADD048052~ SBRP18XYZ1234567*****16~ AMTD50.00~ OIYY~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ NM1PR2HAPPY HEALTH PLAN***XVH9999~ N3705 E HUGH ST~ N4NORFOLKVA235049999~ 837 Institutional Companion Guide Version 38.0/July 2016 . 46 REFT4Y~ LX1~ SV20300HC:D099950.00UN1~ DTP472D820120330~ SVDH999950.00HC:D099903001~ DTP573D820120401~ SE410039~ GE135~ IEA1000000032~ 837 Institutional Companion Guide Version 38.0/July 2016 . 47 9.9 Paper Generated Institutional Encounter Business Scenario 9: Patient/subscriber, Mary Dough, receives services from Mercy Center. Mercy Center submits the claim to Happy Health Plan on a UB-04. Happy Health Plan is the MAO and converts the paper claim into an electronic submission. File String 9: ISA00* 00 ZZENH9999 ZZ80881 120816114 4^005010000000321P:~ GSHCENH99998088120120816114435X005010X223A2~ ST8370039005010X223A2~ BHT0019003920394930203201208141615CH~ NM1412HAPPY HEALTH PLAN****46ENH9999~ PERICMICAH THOMASTE5555552222~ NM1402EDSCMS***4680881~ HL1201~ NM1852MERCY CENTER***XX1234999999~ N3876 MERCY DRIVE~ N4NORFOLKVA235089999~ REFEI128752354~ PERICELIZABETH SMITHTE9195551111~ HL21220~ SBRS18XYZ1234567****MA~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ DMGD819390807F~ NM1PR2EDSCMS****PI80881~ N37500 SECURITY BLVD~ N4BALTIMOREMD212441850~ REF2UH9999~ CLM22350578967509876984536578799A50.00*83:A:1AYY~ DTP434RD820120330-20120331~ CL19901~ PWKOZAA~ HIBK:78099~ SBRP18XYZ1234567*****16~ AMTD50.00~ OIYY~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ NM1PR2HAPPY HEALTH PLAN***XVH9999~ N3705 E HUGH ST~ 837 Institutional Companion Guide Version 38.0/July 2016 . 48 N4NORFOLKVA235049999~ REFT4Y~ LX1~ SV20300HC:D099950.00UN1~ DTP472D820120330~ SVDH999950.00HC:D099903001~ DTP573D820120403~ SE420039~ GE135~ IEA1000000032~ 837 Institutional Companion Guide Version 38.0/July 2016 . 49 9.10 True Coordination of Benefits Institutional Encounter Business Scenario 10: Patient/subscriber, Mary Dough, was admitted into Mercy Hospital complaining of heart pain. Mercy Hospital diagnosed Mary with congestive heart failure and diabetes. Happy Health Plan is the MAO submitting the encounter to CMS. Mary Dough also has healthcare coverage through Other Health Plan, the secondary payer, who has distributed a payment for Mary. File String 10: ISA00* 00 ZZENH9999 ZZ80881 120816114 4^005010000000311P:~ GSHCENH99998088120120816114431X005010X223A2~ ST8370034005010X223A2~ BHT0019003920394930203201208141615CH~ NM1412HAPPY HEALTH PLAN****46ENH9999~ PERICMICAH THOMASTE5555552222~ NM1402EDSCMS***4680881~ HL1201~ NM1852MERCY HOSPITAL***XX1299999999~ N3876 MERCY DRIVE~ N4NORFOLKVA235089999~ REFEI344232321~ PERICELIZABETH SMITHTE9195551111~ HL21220~ SBRS18XYZ1234567****MA~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ DMGD819390807F~ NM1PR2EDSCMS****PI80881~ N37500 SECURITY BLVD~ N4BALTIMOREMD212441850 REF2UH9999~ CLM22350578967509876984536578799A712.00*11:A:1AYY~ DTP096TM0958~ DTP434RD820120330-20120331~ DTP435D820120330~ CL12901~ HIBK:78901~ NM1711JONESAMANDAAL**XX1005554104~ SBRP18XYZ1234567****16~ AMTD700.00 OIYY~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ 837 Institutional Companion Guide Version 38.0/July 2016 . 50 N4NORFOLKVA235099999~ NM1PR2HAPPY HEALTH PLAN***XVH9999~ N3705 E HUGH ST~ N4NORFOLKVA235049999~ SBRT18XYZ3489388****16~ CASCO223700.00~ AMTD12.00~ OI*YY~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ NM1PR2OTHER HEALTH PLAN***XVPAYER01~ N3400 W 21 ST~ N4NORFOLKVA235059999~ DTP573D820120401~ REFT4Y LX1~ SV20300HC:81099712.00UN1~ DTP472D820120330~ SVDH9999700.00HC:D099903001~ CASCO4512.00~ DTP573D820120401~ SE560034~ GE131~ IEA1000000031~ 837 Institutional Companion Guide Version 38.0/July 2016 . 51 9.11 Bundled Institutional Encounter Business Scenario 11: Patient/subscriber, Mary Dough, was admitted into Mercy Hospital complaining of heart pain. Happy Health Plan was the MAO. Mercy Hospital diagnosed Mary with Congestive Health Failure as the primary diagnosis and diabetes. File String 11: ISA00* 00 ZZENH9999 ZZ80881 120816114 4^005010000000311P:~ GSHCENH99998088120120816114431X005010X223A2~ ST8370034005010X223A2~ BHT0019003920394930203201208141615CH~ NM1412HAPPY HEALTH PLAN****46ENH9999~ PERICMICAH THOMASTE5555552222~ NM1402EDSCMS***4680881~ HL1201~ NM1852MERCY HOSPITAL***XX1299999999~ N3876 MERCY DRIVE~ N4NORFOLKVA235089999~ REFEI344232321~ PERICELIZABETH SMITHTE9195551111~ HL21220~ SBRS18XYZ1234567****MA~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ DMGD819390807F~ NM1PR2EDSCMS****PI80881~ N37500 SECURITY BLVD~ N4BALTIMOREMD212441850 REF2UH9999~ CLM22350578967509876984536578798A100.00*11:A:1AYY~ DTP096TM0958~ DTP434RD820120330-20120331~ DTP435D820120330~ CL12901~ HIBK:4280~ HIBJ:4280~ HIBF:25000~ HIBR:3121:D8:20120330~ HIBH:41:D8:20110501BH:27:D8:20110715BH:33:D8:20110718BH:C2:D8:20110729~ HIBE:30:::20~ HIBG:01~ NM1711JONESAMANDAAL*XX1005554104~ 837 Institutional Companion Guide Version 38.0/July 2016 . 52 SBRP18XYZ1234567****16~ AMTD9.48~ OIYY~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ NM1PR2HAPPY HEALTH PLAN***XVH9999~ N3705 E HUGH ST~ N4NORFOLKVA235049999~ REFT4Y~ LX1~ SV2HC:8237450.00UN1*1~ DTP472D820120401~ SVDH99999.48HC:800511~ CASCO4540.52~ DTP573D820120403~ LX2~ SV2HC:8243550.00UN111~ DTP472D820120401~ SVDH99990.00HC:8005111~ CASOA9750.00~ DTP573D820120403~ SE570034~ GE131~ IEA1000000031~ 837 Institutional Companion Guide Version 38.0/July 2016 . 53 9.12 Skilled Nursing Facility Encounter Business Scenario 12: Patient/subscriber, Mary Dough, was admitted into Mercy Health and Rehabilitation SNF for intensive physical therapy services. Happy Health Plan was the MAO. The SNF admitted Mary for inpatient monitoring and physical therapy for a fractured femur. Her length of stay was from 07/10/2014 through 07/26/2014. File String 12: ISA00 00 ZZENH9999 ZZ80881 120816114 4^005010000000311P:~ GSHCENH99998088120120816114431X005010X223A2~ ST8370034005010X223A2~ BHT0019003920394930203201208141615CH~ NM1412HAPPY HEALTH PLAN****46ENH9999~ PERICMICAH THOMASTE5555552222~ NM1402EDSCMS***4680881~ HL1201~ NM1852MERCY HEALTH AND REHAB***XX1299999999~ N3876 MERCY DRIVE~ N4NORFOLKVA235089999~ REFEI344232321~ PERICELIZABETH SMITHTE9195551111~ HL21220~ SBRS18XYZ1234567****MA~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ DMGD819390807F~ NM1PR2EDSCMS****PI80881~ N37500 SECURITY BLVD~ N4BALTIMOREMD212441850 REF2UH9999~ CLM22350578967509876984536578798A25453.42*21:A:1AYY~ DTP096TM0958~ DTP434RD820140710-20140726~ DTP435D820140710~ CL12901~ HIBK:82021 HIBJ:82021 HIBH:50:D8:20140726~ NM1711LEACHELIZAAL**XX1005554104~ SBRP18XYZ1234567****16~ AMTD25453.42~ OIYY~ 837 Institutional Companion Guide Version 38.0/July 2016 . 54 NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ NM1PR2HAPPY HEALTH PLAN***XVH9999~ N3705 E HUGH ST~ N4NORFOLKVA235049999~ REFT4Y~ LX1~ SV20022HP:RML210UN1**1~ LX2~ SV20420HC:9711025453.42UN14~ DTP472RD820140712-20140726~ SVDH999925453.42HC:98925002214~ DTP573D820140930~ SE570034~ GE131~ IEA1*000000031~ 837 Institutional Companion Guide Version 38.0/July 2016 . 55 10.0 Encounter Data Institutional Processing and Pricing System Edits After an Institutional encounter passes translator and CEM level editing and receives an ICN	Jul2016_CG_837I_5CR_081016.pdf
48 N4NORFOLKVA235049999~ REFT4Y~ LX1~ SV20300HC:D099950.00UN1~ DTP472D820120330~ SVDH999950.00HC:D099903001~ DTP573D820120403~ SE420039~ GE135~ IEA1000000032~ 837 Institutional Companion Guide Version 38.0/July 2016 . 49 9.10 True Coordination of Benefits Institutional Encounter Business Scenario 10: Patient/subscriber, Mary Dough, was admitted into Mercy Hospital complaining of heart pain. Mercy Hospital diagnosed Mary with congestive heart failure and diabetes. Happy Health Plan is the MAO submitting the encounter to CMS. Mary Dough also has healthcare coverage through Other Health Plan, the secondary payer, who has distributed a payment for Mary. File String 10: ISA00 00 ZZENH9999 ZZ80881 120816114 4^005010000000311P:~ GSHCENH99998088120120816114431X005010X223A2~ ST8370034005010X223A2~ BHT0019003920394930203201208141615CH~ NM1412HAPPY HEALTH PLAN****46ENH9999~ PERICMICAH THOMASTE5555552222~ NM1402EDSCMS***4680881~ HL1201~ NM1852MERCY HOSPITAL***XX1299999999~ N3876 MERCY DRIVE~ N4NORFOLKVA235089999~ REFEI344232321~ PERICELIZABETH SMITHTE9195551111~ HL21220~ SBRS18XYZ1234567****MA~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ DMGD819390807F~ NM1PR2EDSCMS****PI80881~ N37500 SECURITY BLVD~ N4BALTIMOREMD212441850 REF2UH9999~ CLM22350578967509876984536578799A712.00*11:A:1AYY~ DTP096TM0958~ DTP434RD820120330-20120331~ DTP435D820120330~ CL12901~ HIBK:78901~ NM1711JONESAMANDAAL**XX1005554104~ SBRP18XYZ1234567****16~ AMTD700.00 OIYY~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ 837 Institutional Companion Guide Version 38.0/July 2016 . 50 N4NORFOLKVA235099999~ NM1PR2HAPPY HEALTH PLAN***XVH9999~ N3705 E HUGH ST~ N4NORFOLKVA235049999~ SBRT18XYZ3489388****16~ CASCO223700.00~ AMTD12.00~ OI*YY~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ NM1PR2OTHER HEALTH PLAN***XVPAYER01~ N3400 W 21 ST~ N4NORFOLKVA235059999~ DTP573D820120401~ REFT4Y LX1~ SV20300HC:81099712.00UN1~ DTP472D820120330~ SVDH9999700.00HC:D099903001~ CASCO4512.00~ DTP573D820120401~ SE560034~ GE131~ IEA1000000031~ 837 Institutional Companion Guide Version 38.0/July 2016 . 51 9.11 Bundled Institutional Encounter Business Scenario 11: Patient/subscriber, Mary Dough, was admitted into Mercy Hospital complaining of heart pain. Happy Health Plan was the MAO. Mercy Hospital diagnosed Mary with Congestive Health Failure as the primary diagnosis and diabetes. File String 11: ISA00* 00 ZZENH9999 ZZ80881 120816114 4^005010000000311P:~ GSHCENH99998088120120816114431X005010X223A2~ ST8370034005010X223A2~ BHT0019003920394930203201208141615CH~ NM1412HAPPY HEALTH PLAN****46ENH9999~ PERICMICAH THOMASTE5555552222~ NM1402EDSCMS***4680881~ HL1201~ NM1852MERCY HOSPITAL***XX1299999999~ N3876 MERCY DRIVE~ N4NORFOLKVA235089999~ REFEI344232321~ PERICELIZABETH SMITHTE9195551111~ HL21220~ SBRS18XYZ1234567****MA~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ DMGD819390807F~ NM1PR2EDSCMS****PI80881~ N37500 SECURITY BLVD~ N4BALTIMOREMD212441850 REF2UH9999~ CLM22350578967509876984536578798A100.00*11:A:1AYY~ DTP096TM0958~ DTP434RD820120330-20120331~ DTP435D820120330~ CL12901~ HIBK:4280~ HIBJ:4280~ HIBF:25000~ HIBR:3121:D8:20120330~ HIBH:41:D8:20110501BH:27:D8:20110715BH:33:D8:20110718BH:C2:D8:20110729~ HIBE:30:::20~ HIBG:01~ NM1711JONESAMANDAAL*XX1005554104~ 837 Institutional Companion Guide Version 38.0/July 2016 . 52 SBRP18XYZ1234567****16~ AMTD9.48~ OIYY~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ NM1PR2HAPPY HEALTH PLAN***XVH9999~ N3705 E HUGH ST~ N4NORFOLKVA235049999~ REFT4Y~ LX1~ SV2HC:8237450.00UN1*1~ DTP472D820120401~ SVDH99999.48HC:800511~ CASCO4540.52~ DTP573D820120403~ LX2~ SV2HC:8243550.00UN111~ DTP472D820120401~ SVDH99990.00HC:8005111~ CASOA9750.00~ DTP573D820120403~ SE570034~ GE131~ IEA1000000031~ 837 Institutional Companion Guide Version 38.0/July 2016 . 53 9.12 Skilled Nursing Facility Encounter Business Scenario 12: Patient/subscriber, Mary Dough, was admitted into Mercy Health and Rehabilitation SNF for intensive physical therapy services. Happy Health Plan was the MAO. The SNF admitted Mary for inpatient monitoring and physical therapy for a fractured femur. Her length of stay was from 07/10/2014 through 07/26/2014. File String 12: ISA00 00 ZZENH9999 ZZ80881 120816114 4^005010000000311P:~ GSHCENH99998088120120816114431X005010X223A2~ ST8370034005010X223A2~ BHT0019003920394930203201208141615CH~ NM1412HAPPY HEALTH PLAN****46ENH9999~ PERICMICAH THOMASTE5555552222~ NM1402EDSCMS***4680881~ HL1201~ NM1852MERCY HEALTH AND REHAB***XX1299999999~ N3876 MERCY DRIVE~ N4NORFOLKVA235089999~ REFEI344232321~ PERICELIZABETH SMITHTE9195551111~ HL21220~ SBRS18XYZ1234567****MA~ NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ DMGD819390807F~ NM1PR2EDSCMS****PI80881~ N37500 SECURITY BLVD~ N4BALTIMOREMD212441850 REF2UH9999~ CLM22350578967509876984536578798A25453.42*21:A:1AYY~ DTP096TM0958~ DTP434RD820140710-20140726~ DTP435D820140710~ CL12901~ HIBK:82021 HIBJ:82021 HIBH:50:D8:20140726~ NM1711LEACHELIZAAL**XX1005554104~ SBRP18XYZ1234567****16~ AMTD25453.42~ OIYY~ 837 Institutional Companion Guide Version 38.0/July 2016 . 54 NM1IL1DOUGHMARY**MI672148306~ N31234 STATE DRIVE~ N4NORFOLKVA235099999~ NM1PR2HAPPY HEALTH PLAN***XVH9999~ N3705 E HUGH ST~ N4NORFOLKVA235049999~ REFT4Y~ LX1~ SV20022HP:RML210UN1**1~ LX2~ SV20420HC:9711025453.42UN14~ DTP472RD820140712-20140726~ SVDH999925453.42HC:98925002214~ DTP573D820140930~ SE570034~ GE131~ IEA1*000000031~ 837 Institutional Companion Guide Version 38.0/July 2016 . 55 10.0 Encounter Data Institutional Processing and Pricing System Edits After an Institutional encounter passes translator and CEM level editing and receives an ICN on the 277CA acknowledgement report, the EDFES then transfers the encounter to the Encounter Data Institutional Processing and Pricing System (EDIPPS), where editing, processing, pricing, and storage occurs. In order to assist MAOs and other entities with submission of encounter data through the EDIPPS, CMS has provided the current list of the EDIPPS edits identified in Table 14. Note: The edit descriptions listed into Table 14 were revised to identify a maximum of 41 characters in order to display a more comprehensive explanation of edits on the MAO-002 Reports. The EDIPPS edits are organized in nine (9) different categories, as provided in Table 14, Column 2. The EDIPPS edit categories include the following: • • • • • • • • • Validation Provider Beneficiary Reference Limit Conflict Pricing Duplicate NCCI Table 14, Column 3 identifies two (2) edit dispositions: Informational and Reject. Informational edits will cause the encounter to be flagged; however, the Informational edit will not cause processing and/or pricing to cease. Reject edits will cause an encounter to stop processing and/or pricing, and the MAO or other entity must resubmit the encounter through the EDFES. The encounter must then pass translator and C1 level editing prior to transferring the data to the EDIPPS for reprocessing. The EDIPPS edit description, as found in Table 14, Column 4, is included on the EDPS transaction reports to provide further information for the MAO or other entity to identify the specific reason for the edit generated. If there is no reject edit at the header level and at least one of the lines is accepted, then the encounter is accepted. If there is no reject edit at the header level, but all lines reject, then the encounter will reject. If there is a reject edit at the header level, the encounter will reject. Table 14 reflects only the currently programmed EDIPPS edits. MAOs and other entities should note that, as testing progresses, it may be determined that the current edits require modifications, additional edits may be necessary, or edits may be deactivated. MAOs and other entities must always reference the most recent version of the CMS EDS 837-I Companion Guide to determine the current edits in the EDIPPS. 837 Institutional Companion Guide Version 38.0/July 2016 . 56 TABLE 14 – ENCOUNTER DATA INSTITUTIONAL PROCESSING AND PRICING SYSTEM (EDIPPS) EDITS EDIPPS EDIT# EDIPPS EDIT CATEGORY EDIPPS EDIT DESCRIPTION EDIPPS EDIT ERROR MESSAGE 00010 Validation Reject From DOS Greater Than TCN Date 00011 Validation Reject Missing DOS in Header/Line 00012 Validation Reject DOS Prior to 2012 00025 Validation Reject Through DOS After Receipt Date 00030 Validation Reject ICD-10 Dx Not Allowed 00035 Validation Reject ICD-9 Dx Not Allowed 00175 Validation Reject Verteporfin 00195 Validation Informational Wrong Setting for Autologous PRP 00200 Validation Informational Clinical Trial Billing Error 00265 Validation Reject Correct/Replace or Void ICN Not in EODS 00699 Validation Reject Void Must Match Original 00750 Pricing Reject Service(s) Not Covered Prior To 4/1/2013 00755 Validation Reject Void Encounter Already Void/Adjusted 00760 Validation Reject Adjusted Encounter Already Void/Adjusted 00762 Validation Reject Unable to Void Rejected Encounter 00764 Validation Reject Original Must Be Chart Review to Void 00765 Validation Reject Original Must Be Chart Review to Adjust 00775 Validation Reject Unable to Adjust Rejected Encounter 00780 Validation Reject Adjustment Must Match Original 00785 Validation Reject Linked Encounter Not in EODS 00790 Validation Reject Linked Encounter is Voided/Adjusted 00795 Validation Reject Linked Encounter is Rejected 00800 Validation Reject Parent ICN Not Allowed for Original 00805 Validation Reject Deleted Diagnosis Code Note Allowed 01405 Provider Reject Sanctioned Provider 01415 Provider Informational Rendering Provider Not Eligible For DOS 02106 Beneficiary Informational Invalid Beneficiary Last Name 02110 Beneficiary Reject Beneficiary HICN Not On File 02112 Beneficiary Reject DOS After Beneficiary DOD 02120 Beneficiary Reject Beneficiary Gender Mismatch 02125 Beneficiary Reject Beneficiary DOB Mismatch 02240 Beneficiary Reject Beneficiary Not Enrolled In MAO For DOS 02256 Beneficiary Reject Beneficiary Not Part C Eligible For DOS 03015 Validation Reject HCPCS Code Invalid for DOS 03022 Pricing Reject Invalid CMG for IRF Encounter 03165 Validation Reject Telehealth Facility Fee Not Allowed 17085 Validation Reject CC 40 Required for Same Day Transfer 17100 Validation Reject DOS Required for HH Encounter 17257 Validation Informational Rev Code 091X Not Allowed 17310 Validation Reject Rev Code 036X Requires Surg Proc Code 837 Institutional Companion Guide Version 38.0/July 2016 . 57 TABLE 14 – ENCOUNTER DATA INSTITUTIONAL PROCESSING AND PRICING SYSTEM (EDIPPS) EDITS EDIPPS EDIT# EDIPPS EDIT CATEGORY EDIPPS EDIT DESCRIPTION EDIPPS EDIT ERROR MESSAGE 17330 Reference Reject RAP Not Allowed 17404 Validation Reject Duplicate CPT/HCPCS and Unit Exceeds 1 17407 Validation Reject Modifier Requires HCPCS Code 17735 Validation Reject Modifier Not Within Effective Date 18010 Reference Informational Age and Dx Code Conflict 18012 Reference Informational Gender and Dx Code Conflict 18018 Reference Informational Gender and CPT/HCPCS Conflict 18130 Reference Reject Duplicate Principal Dx Code 18135 Reference Reject Principal Dx Code is Manifestation Code 18140 Reference Reject Principal Dx Code is E-Code 18145 Reference Reject Unacceptable Dx Code 18260 Reference Reject HCPCS Required with Submitted Rev Code 18270 Validation Informational Rev Code and HCPCS Required 18300 Validation Reject FQHC Payment Code is Invalid/Missing 18305 Validation Reject Invalid/Missing FQHC Qualifying Visit 18310 Validation Reject Required FQHC Revenue Code is Missing 18315 Validation Reject Item/Service Not Covered Under FQHC 18500 Conflict Informational Multiple CPT/HCPCS for Same Service 18540 Reference Informational CPT/HCPCS Service Unit Out Of Range 18705 Validation Reject Invalid Discharge Status 18710 Validation Reject Missing/Invalid POA Indicator 18730 Reference Informational Invalid Modifier Format 18905 Validation Reject Age Is 0 Or Exceeds 124 20270 Validation Reject From & Thru Dates Equal - Day Count > 1 20450 Validation Reject Attending Physician is Sanctioned 20455 Validation Informational Operating Provider Is Sanctioned 20495 Validation Reject Revenue Code is Non-Billable for TOB 20500 Conflict Reject Invalid DOS for Rev Code Billed 20505 Conflict Reject Correct Ambulance HCPCS/Rev Code Required 20510 Conflict Reject Rev Code 054X Requires Specific HCPCS 20515 Conflict Informational Immunization Dx Must Align with HCPCS 20520 Validation Informational Invalid Ambulance Pick-up Location 20525 Validation Reject Multiple Ambulance Pick-up Locations 20530 Validation Informational Missing Ambulance Pick-up Zip Code 20835 Pricing Reject Service Line DOS Not Within Header DOS 20980 Pricing Informational Provider Cannot Bill TOB 12X or 22X 21925 Pricing Reject Swing Bed SNF Conditions Not Met 21950 Pricing Reject Line Level DOS Required 21951 Pricing Informational No OSC 70 or Covered Days Less Than 3 21958 Pricing Informational Rehab Therapy Ancillary Codes Required 837 Institutional Companion Guide Version 38.0/July 2016 . 58 TABLE 14 – ENCOUNTER DATA INSTITUTIONAL PROCESSING AND PRICING SYSTEM (EDIPPS) EDITS EDIPPS EDIT# EDIPPS EDIT CATEGORY EDIPPS EDIT DESCRIPTION EDIPPS EDIT ERROR MESSAGE 21976 Validation Informational OSC 70 Dates Outside of Coverage Period 21979 Validation Reject Charges for Rev Code 0022 Must Be Zero 21980 Validation Reject CC D2 Requires Change in One HIPPS 21994 Validation Informational From Date Greater Than Admit Date 22015 Validation Informational Number of Days Conflicts With HH Episode 22020 Validation Informational Conflict Between CC and OSC 22095 Validation Reject Encounter Must Be Submitted on 837-P DME 22100 Validation Informational Rev Code 0023 Invalid for DOS 22135 Validation Reject Multiple Rev Code 0023 Lines Present 22205 Validation Reject Service Line Missing DOS 22220 Validation Reject Admit/Provider Effective Date Conflict 22225 Validation Informational Missing Provider Specific Record 22280 Validation Reject Rev Code 277 Invalid for a HH 22290 Validation Reject Service Line Requires DOS 22320 Validation Informational Missing ASC Procedure Code 22340 Validation Reject ESRD Diagnosis Code Missing 22355 Validation Reject Inpatient Service Line Error 22375 Validation Reject Item/Service Not Covered for RHC 22390 Validation Reject HIPPS Code Required for SNF/HH (DOS on or after 7/1/2014) 22395 Validation Reject HIPPS Codes Conflicts with Revenue Code (DOS on or after 7/1/2014) 22400 Validation Reject HP Qualifier Must Exist for HIPPS Code (DOS on or after 7/1/2014) 22405 Validation Reject Occurrence Code 55 & DOD Required (DOS on or after 01/01/2013) 22410 Pricing Reject Invalid Service(s) for TOB 22415 Pricing Reject Revenue Code 0274 Required 22420 Validation Reject TOB 33X Invalid for DOS 22430 Validation Reject HCPCS Codes with Invalid TOB 25000 NCCI Informational CCI Error 27000 Validation Reject Height or Weight Value Exceeds Limit 98300 Duplicate Reject Exact Inpatient Duplicate Encounter 98315 Duplicate Reject Linked Chart Review Duplicate 98320 Duplicate Reject Chart Review Duplicate 98325 Duplicate Reject Service Line(s) Duplicated 837 Institutional Companion Guide Version 38.0/July 2016 . 59 10.1 EDIPPS Edits Enhancements Implementation Dates As the EDS matures, the EDPS may require enhancements to the EDIPPS editing logic. As enhancements occur, CMS will provide the updated information (i.e., disposition changes and activation or deactivation of an edit). Table 15 provides MAOs and other entities with the implementation dates for enhancements made to the EDIPPS since the last release of the CMS EDS 837-I Companion Guide. TABLE 15 – EDIPPS EDITS ENHANCEMENTS IMPLEMENTATION DATES EDIT EDIT DISPOSITION EDIT DESCRIPTION ENHANCEMENT ENHANCEMENT DATE 00800 Reject Parent ICN Not Allowed for Original New Edit Implemented 7/8/16 00805 Reject Deleted Diagnosis Code Not Allowed New Edit Implemented 7/8/16 18730 Informational Invalid Modifier Format Changed to Informational Disposition 7/8/16 22375 Reject Item/Service Not Covered For RHC New Edit Implemented 7/8/16 Note: Table 15 will not be provided when there are no enhancements implemented for the current	Jul2016_CG_837I_5CR_081016.pdf
Header DOS 20980 Pricing Informational Provider Cannot Bill TOB 12X or 22X 21925 Pricing Reject Swing Bed SNF Conditions Not Met 21950 Pricing Reject Line Level DOS Required 21951 Pricing Informational No OSC 70 or Covered Days Less Than 3 21958 Pricing Informational Rehab Therapy Ancillary Codes Required 837 Institutional Companion Guide Version 38.0/July 2016 . 58 TABLE 14 – ENCOUNTER DATA INSTITUTIONAL PROCESSING AND PRICING SYSTEM (EDIPPS) EDITS EDIPPS EDIT# EDIPPS EDIT CATEGORY EDIPPS EDIT DESCRIPTION EDIPPS EDIT ERROR MESSAGE 21976 Validation Informational OSC 70 Dates Outside of Coverage Period 21979 Validation Reject Charges for Rev Code 0022 Must Be Zero 21980 Validation Reject CC D2 Requires Change in One HIPPS 21994 Validation Informational From Date Greater Than Admit Date 22015 Validation Informational Number of Days Conflicts With HH Episode 22020 Validation Informational Conflict Between CC and OSC 22095 Validation Reject Encounter Must Be Submitted on 837-P DME 22100 Validation Informational Rev Code 0023 Invalid for DOS 22135 Validation Reject Multiple Rev Code 0023 Lines Present 22205 Validation Reject Service Line Missing DOS 22220 Validation Reject Admit/Provider Effective Date Conflict 22225 Validation Informational Missing Provider Specific Record 22280 Validation Reject Rev Code 277 Invalid for a HH 22290 Validation Reject Service Line Requires DOS 22320 Validation Informational Missing ASC Procedure Code 22340 Validation Reject ESRD Diagnosis Code Missing 22355 Validation Reject Inpatient Service Line Error 22375 Validation Reject Item/Service Not Covered for RHC 22390 Validation Reject HIPPS Code Required for SNF/HH (DOS on or after 7/1/2014) 22395 Validation Reject HIPPS Codes Conflicts with Revenue Code (DOS on or after 7/1/2014) 22400 Validation Reject HP Qualifier Must Exist for HIPPS Code (DOS on or after 7/1/2014) 22405 Validation Reject Occurrence Code 55 & DOD Required (DOS on or after 01/01/2013) 22410 Pricing Reject Invalid Service(s) for TOB 22415 Pricing Reject Revenue Code 0274 Required 22420 Validation Reject TOB 33X Invalid for DOS 22430 Validation Reject HCPCS Codes with Invalid TOB 25000 NCCI Informational CCI Error 27000 Validation Reject Height or Weight Value Exceeds Limit 98300 Duplicate Reject Exact Inpatient Duplicate Encounter 98315 Duplicate Reject Linked Chart Review Duplicate 98320 Duplicate Reject Chart Review Duplicate 98325 Duplicate Reject Service Line(s) Duplicated 837 Institutional Companion Guide Version 38.0/July 2016 . 59 10.1 EDIPPS Edits Enhancements Implementation Dates As the EDS matures, the EDPS may require enhancements to the EDIPPS editing logic. As enhancements occur, CMS will provide the updated information (i.e., disposition changes and activation or deactivation of an edit). Table 15 provides MAOs and other entities with the implementation dates for enhancements made to the EDIPPS since the last release of the CMS EDS 837-I Companion Guide. TABLE 15 – EDIPPS EDITS ENHANCEMENTS IMPLEMENTATION DATES EDIT EDIT DISPOSITION EDIT DESCRIPTION ENHANCEMENT ENHANCEMENT DATE 00800 Reject Parent ICN Not Allowed for Original New Edit Implemented 7/8/16 00805 Reject Deleted Diagnosis Code Not Allowed New Edit Implemented 7/8/16 18730 Informational Invalid Modifier Format Changed to Informational Disposition 7/8/16 22375 Reject Item/Service Not Covered For RHC New Edit Implemented 7/8/16 Note: Table 15 will not be provided when there are no enhancements implemented for the current release of the CMS EDS Companion Guides. 10.2 EDIPPS Edits Prevention and Resolution Strategies In order to assist MAOs and other entities with the prevention of potential errors in their encounter data submission and with resolution of edits received on the generated MAO-002 reports, CMS has provided comprehensive strategies and scenarios. CMS has identified strategies and scenarios in three (3) phases. 10.2.1 EDIPPS Edits Prevention and Resolution Strategies – Phase I: Frequently Generated EDIPPS Edits Table 16 outlines Phase 1 of the prevention and resolution strategies for Institutional edits most frequently generated on the MAO-002 reports. TABLE 16 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE I Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 17310 Rev Code 036X Requires Surg Proc Code Reject Revenue Code 036X must be submitted with a required surgical ICD-9 CM procedure code for TOBs 11X, 18X, or 21X. Scenario: Life and Health Associates submitted an encounter for Galaxy Suburb Hospital for a prostate cryosurgery performed on 5/15/2012. The encounter was populated with Revenue Code of 036X, but did not include ICD-9-CM procedure code 6062. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 17407 Modifier Requires HCPCS Code Reject Service line submitted with HCPCS modifier, but not the required HCPCS code. Verify that codes/ modifiers are accurate. 837 Institutional Companion Guide Version 38.0/July 2016 . 60 Scenario: Dr. Whitty submitted the HCPCS modifier code 25- Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure, without the appropriate level of E&M service. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 17735 Modifier Not Within Effective Date Reject Modifier not active for DOS reported. Submitter must verify that modifiers reported are valid and current. Scenario: As a follow up to a postoperative surgery on 8/1/2012, Dr. Whitty submitted HCPCS modifier code 21- Prolonged evaluation and management services on 9/28/2012; however, the modifier was deactivated on 9/1/2012. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 20270 From & Thru Dates Equal - Day Count > 1 Reject Inpatient encounter contains same “from” and “through” DOS; however, the day count reported in Loop 2320 MIA15 does not equal 1. Verify that DOS are accurate or that day count is equal to 1. Scenario: Nightline Hospital admitted a patient at 8 p.m. on 10/23/2012 and the patient was discharged at 2 p.m. on 10/24/2012. Dawn to Dusk Healthcare submitted the encounter with a day count of “2” for admission, although the overnight stay is considered one (1) day. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 20505 Correct Ambulance HCPCS/Rev Code Required Reject Revenue Code 540 populated without appropriate ambulance HCPCS codes and/or a unit greater than 1 for the HCPCS code. Also provide HCPCS mileage codes. Scenario: Blue Flight Health Plan submitted an encounter for ground ambulance services with Revenue Code 540; however, the HCPCS code was not populated. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 20510 Rev Code 054X Requires Specific HCPCS Reject HCPCS code is not valid for submission with Revenue Code 540. Use an appropriate HCPCS code from the list of HCPCS codes acceptable for submission with Revenue Code 540. Scenario: Blue Flight Health Plan submitted a ground transportation ambulance Revenue Code 540 with a HCPCS code A0021-Out of State Per Mile, which was valid for the service, but is invalid for Medicare. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 20530 Missing Ambulance Pick-up Zip Code Informational Submitter should provide a valid nine (9)-digit ZIP code for ambulance pick-up location on ambulance encounters submitted on an Institutional encounter. (See formatting guidance in Section 5.1, Table 4.) Scenario: Mystery Health Plan submitted an encounter on behalf of Rush Ambulance with an ambulance ZIP code populated as “0” in Loop segment 2300 HI01-05. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 20835 Service Line DOS Not Within Header DOS Reject Line level DOS reported that does not fall within “from” and “through” DOS range reported on header level of encounter. Verify the accuracy of all DOS. Scenario: Who Knows Hospital admitted Janet Doe on 6/1/2012 and discharged her on 6/10/2012. Padre Care Plan submitted an inpatient encounter on behalf of Who Knows Hospital for Ms. Doe. The service line DOS were correct; however, the claim header indicated that Ms. Doe was admitted on 6/6/2012 and discharged on 6/12/2012. 837 Institutional Companion Guide Version 38.0/July 2016 . 61 10.2.2 EDIPPS Edits Prevention and Resolution Strategies – Phase II: Common EDPS Edits Table 17 outlines Phase II for common edits generated in all subsystems of the EDPS (Professional, Institutional, and DME). TABLE 17 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE II Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00010 From DOS Greater Than TCN Date Reject Encounter must have a DOS prior to submission date. Scenario: Perfect Health of America submitted an encounter to the EDS on 5/10/2012 for a knee replacement performed at Wonderful Hills Mediplex for DOS of 6/20/2012. The encounter was rejected because the “from” DOS was after the date of encounter submission. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00011 Missing DOS in Header/Line Reject Encounter header and line levels must include “from” and “through” DOS (procedure or service start date). Scenario: Chloe Pooh was admitted to Regional Port Hospital on 10/21/2012 for a turbinectomy and was released on 10/22/2012. Regional Port Hospital submitted a claim to Robbins Health for the surgical procedure. Robbins Health submitted the encounter to the EDS, but did not include the “through” DOS of 10/22/2012. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00012 DOS Prior to 2012 Reject Encounter must contain 2012 “through” DOS for each line. Scenario: Ion Health submitted an encounter with DOS from 12/2/2011 through 12/28/2011, for an inpatient admission at Better Health Hospital. EDS will only process encounters that include 2012 “through” DOS or later. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00025 Through DOS After Receipt Date Reject Encounter submitted with a service line “through” DOS that occurred after the date the encounter was submitted. Scenario: Leverage Community Health submitted an encounter on 8/23/2012 for a myringotomy performed by Dr. Earwell. The service line DOS for the procedure was on 8/29/2012. The encounter was rejected because the encounter was submitted to the EDS prior to the DOS listed on the encounter. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00265 Correct/Replace or Void ICN Not in EODS Reject Replacement or void encounter submitted with an invalid ICN. Verify accuracy of ICN on the returned MAO-002 report. Scenario: Chance Medical Services submitted an encounter to the EDS and received an MAO-002 report with an accepted ICN of 123456789. The encounter required an adjustment (void or replacement). Chance Medical Services submitted a replacement encounter using ICN 234567899. The replacement encounter was rejected because there was no original record in the EDS for this ICN with the same Submitter ID. 837 Institutional Companion Guide Version 38.0/July 2016 . 62 TABLE 17 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE II (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00699 Void Must Match Original Reject When submitting a void, MAOs must match the linked ICN, HICN, Last Name, First Name, TOB, Submitted Charges, DOS, Payer ID, and the service lines of an accepted encounter stored in the EODS. Note: The EDPS will validate the beneficiary’s demographic data (HICN, Last Name, First Name) according to the Medicare Beneficiary Database (MBD), as well as validate the beneficiary’s Billing Provider NPI and Rendering Provider NPI (if applicable) prior to posting edit 00699. Scenario: Grantham Healthcare submitted an encounter for pre-operation lab work for Juno Brac containing five (5) service lines. Torchlight Healthcare then submitted a void encounter for the same annual physical; however, the void encounter contained only four (4) of the five (5) original service lines. Torchlight Healthcare received an MAO-002 report with edit 00699 for the void encounter because one (1) of the service lines from the original encounter was not included on the void encounter. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 01405 Sanctioned Provider Reject Submitter must ensure that provider (billing and/or rendering) was not suspended or terminated from providing services for Medicare beneficiaries during the time(s) of service indicated on the encounter. Scenario: Dr. Domuch performed a cystectomy for Wally Dowright on 10/2/2012. Dr. Domuch submitted a claim to Dermis Health Plan, who adjudicated the claim and submitted an encounter to the EDS. The EDS returned the encounter to Dermis Health Plan with edit 01405 because Dr. Domuch’s privileges were suspended, effective 8/29/2012, for one (1) year; therefore, Dr. Domuch was not authorized to perform this procedure. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 01415 Rendering Provider Not Eligible For DOS Informational Verify that NPI is accurate and that the provider was eligible for DOS submitted. Scenario: ABC Care Plan submitted an encounter for a procedure performed by Dr. Destiny on 2/14/2012. The EDPS provider reference files indicate that Dr. Destiny’s NPI was not effective until 2/16/2012. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 02106 Invalid Beneficiary Last Name Informational Verify that last name populated on the encounter matches the last name listed in CMS systems. Scenario: Blue Skies Rural Health submitted	Jul2016_CG_837I_5CR_081016.pdf
line DOS for the procedure was on 8/29/2012. The encounter was rejected because the encounter was submitted to the EDS prior to the DOS listed on the encounter. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00265 Correct/Replace or Void ICN Not in EODS Reject Replacement or void encounter submitted with an invalid ICN. Verify accuracy of ICN on the returned MAO-002 report. Scenario: Chance Medical Services submitted an encounter to the EDS and received an MAO-002 report with an accepted ICN of 123456789. The encounter required an adjustment (void or replacement). Chance Medical Services submitted a replacement encounter using ICN 234567899. The replacement encounter was rejected because there was no original record in the EDS for this ICN with the same Submitter ID. 837 Institutional Companion Guide Version 38.0/July 2016 . 62 TABLE 17 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE II (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00699 Void Must Match Original Reject When submitting a void, MAOs must match the linked ICN, HICN, Last Name, First Name, TOB, Submitted Charges, DOS, Payer ID, and the service lines of an accepted encounter stored in the EODS. Note: The EDPS will validate the beneficiary’s demographic data (HICN, Last Name, First Name) according to the Medicare Beneficiary Database (MBD), as well as validate the beneficiary’s Billing Provider NPI and Rendering Provider NPI (if applicable) prior to posting edit 00699. Scenario: Grantham Healthcare submitted an encounter for pre-operation lab work for Juno Brac containing five (5) service lines. Torchlight Healthcare then submitted a void encounter for the same annual physical; however, the void encounter contained only four (4) of the five (5) original service lines. Torchlight Healthcare received an MAO-002 report with edit 00699 for the void encounter because one (1) of the service lines from the original encounter was not included on the void encounter. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 01405 Sanctioned Provider Reject Submitter must ensure that provider (billing and/or rendering) was not suspended or terminated from providing services for Medicare beneficiaries during the time(s) of service indicated on the encounter. Scenario: Dr. Domuch performed a cystectomy for Wally Dowright on 10/2/2012. Dr. Domuch submitted a claim to Dermis Health Plan, who adjudicated the claim and submitted an encounter to the EDS. The EDS returned the encounter to Dermis Health Plan with edit 01405 because Dr. Domuch’s privileges were suspended, effective 8/29/2012, for one (1) year; therefore, Dr. Domuch was not authorized to perform this procedure. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 01415 Rendering Provider Not Eligible For DOS Informational Verify that NPI is accurate and that the provider was eligible for DOS submitted. Scenario: ABC Care Plan submitted an encounter for a procedure performed by Dr. Destiny on 2/14/2012. The EDPS provider reference files indicate that Dr. Destiny’s NPI was not effective until 2/16/2012. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 02106 Invalid Beneficiary Last Name Informational Verify that last name populated on the encounter matches the last name listed in CMS systems. Scenario: Blue Skies Rural Health submitted an encounter for patient Ina Batiste-Rhogin. The CMS system listed the patient as Ina Rhogin. The EDPS processed and accepted the encounter with an informational flag indicating that the name provided on the encounter was not identical to the name listed in the CMS systems. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 02110 Beneficiary HICN Not On File Reject Verify that HICN populated on the encounter is valid in CMS systems. Scenario: Bright Medical Center submitted a claim to Sunshine Complete Health for an office visit for Mr. Everett Banks for DOS of 5/26/2012. Sunshine Complete Health submitted an encounter to the EDS. The EDS rejected the encounter with edit 02110, because the HICN populated on the encounter was not on file in the CMS systems. 837 Institutional Companion Guide Version 38.0/July 2016 . 63 TABLE 17 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE II (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 02112 DOS After Beneficiary DOD Reject Verify that DOS submitted is accurate and does not exceed the beneficiary DOD. Scenario: Mountain Hill Health submitted an encounter for an inpatient admission for Ray Rayson for DOS of 7/15/2012. EDPS was unable to process the encounter because the CMS systems indicated Mr. Rayson expired on 7/13/2012. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 02120 Beneficiary Gender Mismatch Reject Verify that gender populated on the encounter is accurate and matches gender listed in CMS systems. Scenario: Jenna Jorgineski went to Lollipop Lab for a sleep study on 9/4/2012. Lollipop Lab submitted a claim for the sleep study to Capital City Community Care with Ms. Jorgineski’s gender identified as “male”. Capital City Community Care submitted the encounter. The EDS processed and accepted the encounter. The MAO-002 report was returned with edit 02120, because Ms. Jorgineski’s gender was listed as “female” in the CMS systems. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 02125 Beneficiary DOB Mismatch Reject Verify that DOB populated on the encounter matches DOB listed in CMS systems. The EDPS will accept these encounters within plus or minus two (2) years of beneficiary’s birth year. Note: CMS anticipates that the change in this edit will be short-term and expects plan sponsors to improve their submission of DOBs. Scenario: Watchman Health submitted an encounter to the EDS for Texas Joe, listing Mr. Joe’s DOB as 9/8/1965. The CMS systems listed Mr. Joe’s DOB as 9/8/1956. The EDS returned the MAO-002 report to Watchman Health with edit 02125 due to the conflicting dates of birth beyond the two (2)-year variance. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 02240 Beneficiary Not Enrolled In MAO For DOS Reject Verify that beneficiary was enrolled in your contract during DOS on the encounter. If the beneficiary is not enrolled in your contract for the DOS on the encounter, do not submit the encounter. Encounters should only be submitted for DOS in which the beneficiary is enrolled in your contract. Scenario: Gabrielle Boyd was admitted to Faith Hospital for an appendectomy on 6/11/2012 and was discharged on 6/14/2012. Faith Hospital submitted the claim for the hospital admission to Adams Healthcare. Adams Healthcare adjudicated the claim and submitted an encounter to the EDS on 7/12/2012. Ms. Boyd’s effective date with Adams Healthcare was 7/1/2011. The EDS returned an MAO-002 report to Adams Health with edit 02240 because Ms. Boyd was not enrolled with the health plan for the DOS submitted by Faith Hospital. 837 Institutional Companion Guide Version 38.0/July 2016 . 64 TABLE 17 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE II (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 02256 Beneficiary Not Part C Eligible For DOS Reject Verify that beneficiary was enrolled in Part C for DOS listed on the encounter. Encounters should not be submitted for beneficiaries not enrolled with the contract for the DOS on the received claim. Encounters should only be submitted for DOS for which the beneficiary is actually enrolled with your contract. Scenario: On 7/4/2012, Gail Williams has severe chest pains and goes to the emergency room for a chest x-ray at Underwood Memorial Hospital. At the time of the emergency room visit, Ms. Williams only has Part A Medicare coverage, and her Part C Medicare coverage is effective 8/1/2012. Underwood Memorial submits the claim to AmeriHealth. AmeriHealth submits an encounter to the EDS, which is rejected with edit 02256, because Ms. Williams is not covered under Part C Medicare for the DOS. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 25000 CCI Error Informational Ensure CCI code pairs are appropriately used. Ensure that CCI single codes meet the MUE allowable units of service (UOS). Scenario: Hippos Health Plan submitted an encounter to the EDS with a DOS of 5/5/2012 and HCPCS code 15780 and two (2) units of service. The returned MAO-002 report indicated an informational edit of 25000 because HCPCS code 15780 – dermabrasion, is only valid for one (1) unit of service per day. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 98325 Service Line(s) Duplicated Reject Verify encounter was not previously submitted and/or the service line does not contain the exact same data elements as a previously submitted service line on the same encounter (Refer to the Section 8.0 Duplicate Logic in this companion guide for duplicate logic validation elements.) Note: The EDPS will bypass edit logic for 98325 when modifier 59, 62, 66, 76, 77, and/or 91 is submitted on one (1) of multiple service lines containing the exact same data elements. Scenario: Sanford Health Systems submitted an encounter on 6/15/2015 for a claim received from Sky High Hospital containing two (2) service lines for 15-minute therapy services. The encounter lines submitted were the same for the timed procedure code, totaling 35 minutes and should have been submitted with two (2) units of service under the total time rather than as separate duplicate lines. 837 Institutional Companion Guide Version 38.0/July 2016 . 65 10.2.3 EDIPPS Edits Prevention and Resolution Strategies – Phase III: General EDIPPS Edits Table 18 outlines Phase III for a portion of the remaining Institutional edits generated on the MAO-002 Encounter Data Processing Status Reports. Section 10.2.3 will be updated in future releases of the Institutional Companion Guide until all remaining edits are identified. TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00195 Wrong Setting for Autologous PRP Informational Encounters containing HCPCS code G0460 must only be billed with TOB 12X, 13X, 22X, 23X, 71X, 75X, 77X, or 85X. Scenario: New Balance Home Health submitted an encounter for the purpose of billing Autologous Platelet-Rich Plasma (PRP) for a Mr. Garret’s non-healing wound. The service was submitted using HCPCS Code G0460 and TOB 34X. The EDS posted error code 00195 because Home Health providers cannot administer this service. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00200 Clinical Trial Billing Error Informational Clinical trial encounters must contain Modifier “Q0”, Condition Code “30”, and clinical trial-specific ICD-9/10 Diagnosis Code V70.7/Z00.6. Scenario: Coagulate Community Health submitted a clinical trial encounter for patient Mr. Bumbly. The service was submitted with modifier “Q0” and ICD-9 diagnosis code V70.7, but did not contain Condition Code “30”, as required for clinical trial submissions to the EDS. The EDS posted error code 00200 because the clinical trial encounter must contain Condition Code “30”. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18010 Age and Dx Code Conflict Informational Verify that diagnosis populated on the encounter is age appropriate for beneficiary Scenario: Clear Path Health submitted an encounter to the EDS for services provide to Mr. Jackson Leigh, who is 85-yrs old. The diagnosis provided on the encounter was V20.2-routine child health check. The MAO-002 report returned contained an informational edit of 18010 because the diagnosis provided was not appropriate for an 85-yr old. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18018 Gender and CPT/HCPCS Conflict Informational Gender provided for beneficiary does not agree with procedure/service identified on the encounter. Verify gender populated on encounter matches date in the CMS systems. Ensure that the procedure code is accurate and appropriate. Scenario: Claims Health submitted an encounter for Jane Johnson with procedure code 58150-Total Hysterectomy. However, the gender populated on the encounter identified Ms. Johnson as a male. The MAO-002 report was returned with an informational error of 18018. CMS recommends that Claims Health verify the gender on Ms. Johnson’s HICN information to ensure that it is corrected. 837 Institutional Companion Guide Version 38.0/July 2016 . 66 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18135 Principal Dx is Manifestation Code Reject Encounter submitted using a code for underlying disease or symptom instead of a principal diagnosis. Ensure that primary diagnosis is valid. Scenario: Arbor Meadows Health submitted an encounter for an inpatient admission for Ms. Anabel Greaves. The diagnosis submitted on the encounter was 3214-Meningitis due to sarcoidosis. The EDS rejected the encounter because 3214 is not a primary diagnosis, but is a manifestation code for a condition related to the diagnosis. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18260 Invalid Rev Code Reject Encounter submitted with a Revenue Code not	Jul2016_CG_837I_5CR_081016.pdf
will be updated in future releases of the Institutional Companion Guide until all remaining edits are identified. TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00195 Wrong Setting for Autologous PRP Informational Encounters containing HCPCS code G0460 must only be billed with TOB 12X, 13X, 22X, 23X, 71X, 75X, 77X, or 85X. Scenario: New Balance Home Health submitted an encounter for the purpose of billing Autologous Platelet-Rich Plasma (PRP) for a Mr. Garret’s non-healing wound. The service was submitted using HCPCS Code G0460 and TOB 34X. The EDS posted error code 00195 because Home Health providers cannot administer this service. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00200 Clinical Trial Billing Error Informational Clinical trial encounters must contain Modifier “Q0”, Condition Code “30”, and clinical trial-specific ICD-9/10 Diagnosis Code V70.7/Z00.6. Scenario: Coagulate Community Health submitted a clinical trial encounter for patient Mr. Bumbly. The service was submitted with modifier “Q0” and ICD-9 diagnosis code V70.7, but did not contain Condition Code “30”, as required for clinical trial submissions to the EDS. The EDS posted error code 00200 because the clinical trial encounter must contain Condition Code “30”. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18010 Age and Dx Code Conflict Informational Verify that diagnosis populated on the encounter is age appropriate for beneficiary Scenario: Clear Path Health submitted an encounter to the EDS for services provide to Mr. Jackson Leigh, who is 85-yrs old. The diagnosis provided on the encounter was V20.2-routine child health check. The MAO-002 report returned contained an informational edit of 18010 because the diagnosis provided was not appropriate for an 85-yr old. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18018 Gender and CPT/HCPCS Conflict Informational Gender provided for beneficiary does not agree with procedure/service identified on the encounter. Verify gender populated on encounter matches date in the CMS systems. Ensure that the procedure code is accurate and appropriate. Scenario: Claims Health submitted an encounter for Jane Johnson with procedure code 58150-Total Hysterectomy. However, the gender populated on the encounter identified Ms. Johnson as a male. The MAO-002 report was returned with an informational error of 18018. CMS recommends that Claims Health verify the gender on Ms. Johnson’s HICN information to ensure that it is corrected. 837 Institutional Companion Guide Version 38.0/July 2016 . 66 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18135 Principal Dx is Manifestation Code Reject Encounter submitted using a code for underlying disease or symptom instead of a principal diagnosis. Ensure that primary diagnosis is valid. Scenario: Arbor Meadows Health submitted an encounter for an inpatient admission for Ms. Anabel Greaves. The diagnosis submitted on the encounter was 3214-Meningitis due to sarcoidosis. The EDS rejected the encounter because 3214 is not a primary diagnosis, but is a manifestation code for a condition related to the diagnosis. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18260 Invalid Rev Code Reject Encounter submitted with a Revenue Code not related to services provided or a Revenue Code not used. Scenario: Home Sweet Home submitted a claim to Foundation Health for Home Health services provided to Ms. Jean. Foundation Health submitted the encounter to the EDS using Revenue Code 0022. The encounter was rejected for edit 18260 because Foundation Health used a SNF revenue code for a Home Health encounter. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18270 Rev Code and HCPCS Required Informational Certain revenue codes require HCPCS codes on the same service lines. TOBs 12X, 13X, 14X, 74X, 75X, and 76X billed without condition code 41 and include a relevant revenue code that requires a HCPCS code will receive this edit. Scenario: Julie Barber was seen by Dr. Jo at Saint Mary Hospital for a hearing evaluation. Dr. Jo submitted a TOB 141 encounter with HCPCS code 92506 (Speech/Hearing Evaluation) but did not include revenue code 0440. The MAO submitted the encounter to the EDS which posted edit 18270 to advise the MAO that revenue codes are required with the submitted HCPCS code. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18300 FQHC Payment Code is Invalid/Missing Reject An FQHC encounter (TOB 77X) must include a valid payment HCPCS code (G0466, G0467, G0468, G0469, or G0470) on the encounter service line for each billed service date. Scenario: Heelum Health Center submitted an FQHC encounter using bill type 77X and only submitted HCPCS code G0463. The EDPS rejected the encounter because the encounter did not contain an FQHC payment HCPCS code. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18305 Invalid/Missing FQHC Qualifying Visit Reject FQHC encounters (TOB 77X) must include a qualifying visit procedure code related to the FQHC payment codes G0466, G0467, G0468, G0469, or G0470 for the same date of service. Scenario: Howard Cankle was treated by Heelum Health Center on 11/20/2014 for an annual wellness visit (G0468). Heelum Health Center submitted an encounter (bill type 77X) for Howard Cankle with visit code 92002 (eye exam, new patient). The EDPS rejected the service line because 92002 is not a valid visit code for payment code G0468. 837 Institutional Companion Guide Version 38.0/July 2016 . 67 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18310 Required FQHC Revenue Code is Missing Reject FQHC encounters (TOB 77X) must include a valid revenue code on the same service line for the payment HCPCS codes G0466, G0467, G0468, G0469, or G0470. Scenario: Heelum Health Center submitted an encounter (TOB 77X) for Eileen Bentley’s annual eye exam (FQHC payment code G0467, visit code 92012) and revenue code 0530. The EDPS rejected the service line because revenue code 0530 is used for Osteopathic Services. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18315 Item/Service Not Covered Under FQHC Reject All FQHC encounter service lines must contain only qualified FQHC services. Scenario: Heelum Health Center submitted an encounter (TOB 77X) including a service line for Dr. Smart’s professional fees. The EDPS rejected the service line because Dr. Smart’s professional fees are not acceptable FQHC services even though Dr. Smart is an FQHC provider. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18540 CPT/HCPCS Service Unit Out Of Range Informational Procedures submitted with number of units not permitted by the procedure will receive this edit. Scenario: Cinderella Hospital submitted an encounter with HCPCS code 51860 for the bladder wound repair of Rob Snyder and billed two (2) units for the service. The encounter was rejected because submitters can only bill one (1) unit with HCPCS code 51860. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18705 Invalid Discharge Status Reject Providers must use the correct patient status code in loop 2300 and segment CL103 in conjunction with the submitted type of bill and beneficiary status. Scenario: Crisis Clinton Hospital submitted a TOB 112 encounter for Gary Fargo and the patient status code “01” was populated. The EDS posted edit 18705 as the encounter should have included patient status code “30” (still a patient) since TOB 112 was used for a continuous stay patient. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 21950 Line Level DOS Required Reject Certain procedures/services require date(s) of service at the service line. The EDPS will post error code 21950 when an Institutional encounter submitted with HCPCS codes other than Q0163 through Q0181 does not contain service line date(s) of service. Scenario: Norview East Hospital submitted an encounter for Claire Beauchamp for an inpatient stay where continuous glucose monitoring was performed. The encounter service line contained HCPCS code 95250 but no service line dates of service. The EDS rejected the encounter due to missing DOS at the service line. 837 Institutional Companion Guide Version 38.0/July 2016 . 68 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 21958 Rehab Therapy Ancillary Codes Required Informational The EDS will notify MAOs when Rehabilitation Therapy encounters submitted through TOB 18X or 21X and revenue code 0022 do not contain the proper combination of HIPPS codes and related Rehabilitation Therapy Ancillary Revenue Codes. Scenario: Sleeping Beauty Skilled Nursing Facility (SNF) submitted a TOB 21X encounter containing HIPPS Code RUAxx, but none of the following rehabilitation ancillary codes: 42X, 43X, or 44X. The EDS posted error code 21958 since this encounter contained an inaccurate combination of HIPPS codes and related Rehabilitation Therapy Ancillary Revenue Codes. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 21980 CC D2 Requires Change in One HIPPS Reject Replacement encounter submitted with condition code D2; however, the associated HIPPS code was not revised to indicate the replacement. Scenario: Marxton Health sent a replacement encounter to the EDS on behalf of Here For You Health, which contained condition code of ‘D2” and an appropriate reason code to revise the HIPPs code originally submitted, but the HIPPS code itself was not revised. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00755 Void Encounter Already Void/Adjusted Reject Submitter has previously voided an encounter and is attempting to void the same encounter. Submitter should review returned MAO-002 reports to confirm processing of the voided encounter prior to resubmission of the void. Scenario: Happy Trails Health Plan submitted a void encounter on 10/10/2012. Happy Trails Health Plan voided the same encounter, in error, on 10/15/2012, prior to receiving the MAO-002 report for the initial void encounter, which was returned on 10/16/2012. The MAO-002 report for the subsequent voided encounter was returned with edit 00755 due to the submission of the second void encounter. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00760 Adjusted Encounter Already Void/Adjusted Reject Submitter has previously voided an encounter and is attempting to replace the same voided encounter. Submitter should review returned MAO-002 reports to confirm processing of the voided encounter prior to resubmission replacement. Scenario: On 8/20/2012, Pragmatic Health submitted a replacement encounter for ICN 123456789 to correct a CPT code. However, Pragmatic Health had already submitted a void for the same ICN on 8/18/2012, but had not yet received the MAO-002 report by 8/20/2012. Pragmatic Health received edit 00760 on a subsequent MAO-002 report because the EDPS had already processed the void encounter submitted on 8/18/2012. 837 Institutional Companion Guide Version 38.0/July 2016 . 69 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00762 Unable to Void Rejected Encounter Reject Submitter is attempting to void a previously rejected encounter. Submitter should review returned MAO-002 reports to confirm the rejected encounter. Scenario: On 7/20/2012, Hero Health Plan submitted an encounter with an invalid HICN. On 7/26/2012, Hero Health Plan attempted to void the encounter due to the invalid HICN without referencing the MAO-002 report, dated 7/25/2012, that indicated that the encounter was rejected. On 8/1/2012, Hero Health Plan received an MAO-002 report with edit 00762 for the voided encounter because the original encounter had already been processed and rejected. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 17330 RAP Not Allowed Reject Encounter submissions are not allowed for Type of Bill 322 or 332 (Request for Anticipated Payment) Scenario: Magic Morning Health Plan submitted an encounter to the EDS for BackHome Health (a primary HHA) with TOB 322. The encounter was rejected because the EDS does not accept Request for Anticipated Payment (RAP) encounters. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18012 Gender and Dx Code Conflict Informational Encounter submitted with a beneficiary gender that does not agree with the diagnosis populated on the encounter. Scenario: Hindsight Health submitted an encounter for JuneBug Hospital for Mr. James Jewet with diagnosis code 641.1 – Hemorrhage from placenta previa. The encounter was rejected because the diagnosis submitted is a female specific diagnosis. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18130 Duplicate Principal Dx Code Reject Secondary diagnosis code submitted is a duplicate of the primary diagnosis code. Scenario: Solo Health Services submitted an encounter with a diagnosis code 413.9 in the ‘BK’ (primary diagnosis) and ‘BF’ (additional diagnosis) qualifier fields for the same service line. The encounter was rejected for duplicate primary diagnoses. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18145 Unacceptable Dx Code Reject The diagnosis	Jul2016_CG_837I_5CR_081016.pdf
voided encounter prior to resubmission of the void. Scenario: Happy Trails Health Plan submitted a void encounter on 10/10/2012. Happy Trails Health Plan voided the same encounter, in error, on 10/15/2012, prior to receiving the MAO-002 report for the initial void encounter, which was returned on 10/16/2012. The MAO-002 report for the subsequent voided encounter was returned with edit 00755 due to the submission of the second void encounter. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00760 Adjusted Encounter Already Void/Adjusted Reject Submitter has previously voided an encounter and is attempting to replace the same voided encounter. Submitter should review returned MAO-002 reports to confirm processing of the voided encounter prior to resubmission replacement. Scenario: On 8/20/2012, Pragmatic Health submitted a replacement encounter for ICN 123456789 to correct a CPT code. However, Pragmatic Health had already submitted a void for the same ICN on 8/18/2012, but had not yet received the MAO-002 report by 8/20/2012. Pragmatic Health received edit 00760 on a subsequent MAO-002 report because the EDPS had already processed the void encounter submitted on 8/18/2012. 837 Institutional Companion Guide Version 38.0/July 2016 . 69 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00762 Unable to Void Rejected Encounter Reject Submitter is attempting to void a previously rejected encounter. Submitter should review returned MAO-002 reports to confirm the rejected encounter. Scenario: On 7/20/2012, Hero Health Plan submitted an encounter with an invalid HICN. On 7/26/2012, Hero Health Plan attempted to void the encounter due to the invalid HICN without referencing the MAO-002 report, dated 7/25/2012, that indicated that the encounter was rejected. On 8/1/2012, Hero Health Plan received an MAO-002 report with edit 00762 for the voided encounter because the original encounter had already been processed and rejected. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 17330 RAP Not Allowed Reject Encounter submissions are not allowed for Type of Bill 322 or 332 (Request for Anticipated Payment) Scenario: Magic Morning Health Plan submitted an encounter to the EDS for BackHome Health (a primary HHA) with TOB 322. The encounter was rejected because the EDS does not accept Request for Anticipated Payment (RAP) encounters. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18012 Gender and Dx Code Conflict Informational Encounter submitted with a beneficiary gender that does not agree with the diagnosis populated on the encounter. Scenario: Hindsight Health submitted an encounter for JuneBug Hospital for Mr. James Jewet with diagnosis code 641.1 – Hemorrhage from placenta previa. The encounter was rejected because the diagnosis submitted is a female specific diagnosis. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18130 Duplicate Principal Dx Code Reject Secondary diagnosis code submitted is a duplicate of the primary diagnosis code. Scenario: Solo Health Services submitted an encounter with a diagnosis code 413.9 in the ‘BK’ (primary diagnosis) and ‘BF’ (additional diagnosis) qualifier fields for the same service line. The encounter was rejected for duplicate primary diagnoses. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18145 Unacceptable Dx Code Reject The diagnosis code populated on the encounter is invalid or incorrectly populated. Scenario: Hopewell Health Plan submitted an encounter to the EDS for Cornerstone Hospital for services provide to Colonel Marcus on 2/3/2012. The diagnosis populated on the encounter was 518.5 – Pulmonary Insufficiency Following Trauma or Surgery. The encounter was rejected for an unacceptable diagnosis because diagnosis code was deleted and deemed invalid effective 10/1/2011. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 21994 From Date Greater Than Admit Date Informational Encounter submitted with a 'from' date prior to the date of the beneficiary’s admission. Scenario: Allison Oop was admitted to Mad Hatter Nursing Facility at 2:46 AM on 4/1/2012. Holiday Health submitted the SNF encounter to the EDS with an admit date of 4/1/2012, but the service line from date was listed as 3/29/2012. 837 Institutional Companion Guide Version 38.0/July 2016 . 70 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22220 Admit/Provider Effective Date Conflict Reject Admission date indicated on encounter occurred before the provider’s NPI was deemed active/effective. Note: The EDPS will validate bill types prior to posting edit 22220. Scenario: Halo Home Health submitted an encounter to the EDS for Mr. Sweets’ admission on 1/28/2011 for DOS from 2/1/2012 through 2/11/2012 with NPI 0002220001. The encounter was rejected because the NPI effective date was 2/2/2012, after the admission date. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00764 Original Must Be a Chart Review to Void Reject Submitter must ensure that, if the void encounter (frequency code ‘8’) is populated with PWK01=’09 and PWK02=’AA’, the original encounter submission was a chart review encounter populated with PWK01=’09’ and PWK02=’AA’. The submitter must also ensure that the ICN references the initial chart review encounter, not the original full encounter. Scenario: On 1/12/2013, Paisley Community Health submitted an original encounter for Mr. Jolly Jones to the EDS and received the accepted ICN of 3029683010582. On 2/2/2013, Paisley Community Health submitted a chart review encounter to the EDPS to delete a diagnosis code from the original encounter and received the accepted ICN of 5039530285074. In April 2013, Paisley Community Health performed another chart review of Mr. Jones’ medical records and discovered that the service was never provided. Paisley Community Health submitted a void encounter to the EDS using the reference ICN of 3029683010582 (the original encounter ICN) and populated PWK01=’09’ and PWK02=’AA’. The EDS rejected the encounter because the ICN referenced was for the original encounter, not the initial chart review. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00765 Original Must Be a Chart Review to Adjust Reject Ensure that, if the replacement encounter (frequency code ‘7’) is populated with PWK01=’09 and PWK02=’AA’, the original encounter submission was a chart review encounter populated with PWK01=’09’ and PWK02=’AA’. The submitter must also ensure that the ICN references the initial chart review encounter, not the original encounter. The replacement chart review (frequency code ‘7’) must contain all data elements, including all relevant diagnosis codes populated on the original linked chart review encounter (frequency code ‘1’). Important Note: The accepted replacement chart review submission will supersede any previous chart review encounter to which it is linked. Scenario: Flashback Health performed a chart review for Prosperous Living Medical Center. Flashback Health discovered two (2) additional diagnosis codes for an encounter previously submitted for Ms. Leanne Liberty. Flashback Health submitted an initial chart review encounter using the frequency code of ‘7’. The EDS rejected the chart review encounter submission because initial chart review encounters should contain a frequency code ‘1’. 837 Institutional Companion Guide Version 38.0/July 2016 . 71 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 17404 Duplicate CPT/HCPCS and Unit Exceeds 1 Reject Encounter should not be submitted with a unit of greater than 1 when any of the following HCPCS codes are provided for a pap smear on a single DOS: Q0060, Q0061, P3000, P3001, Q0091, G0123, G0124, G0143, G0144, G0145, G0147, and G0148 nor can duplicate pap smear HCPCS Codes be submitted for the same day. Scenario: Dr. Michaels performed a pap smear on Miss Annabelle Lee prior to a gynecological procedure. The lab lost the test sample. Dr. Michaels repeated the Pap smear and performed the gynecological procedure. Group Health Plan submitted the encounter for both of Miss Lee’s pap smears, using HCPCS code Q0060, and her surgical procedure. The encounter was rejected because Medicare will not allow more than one (1) unit for Q0060 for a single service. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18140 Principal Dx Code is E-Code Reject Submitter must ensure that an e-code is submitted as a subsequent diagnosis code. An E-code is never allowed as a primary/principal diagnosis code and must not be populated using the ‘BK’ qualifier Scenario: Marney Gentos was admitted to Home Hospital for second degree burns. Fantasy Life Health Plan submitted the encounter to the EDS and received an accepted ICN. Fantasy Life Health Plan later performed a chart review and located an additional diagnosis code for services provided during Ms. Gentos’ stay at Home Hospital. Fantasy Life submitted a chart review encounter to the EDS with a single diagnosis code of E9581 – Injury-burn, fire. The EDS rejected the chart review submission because e-codes must never be submitted without a primary/principal diagnosis. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18905 Age Is 0 Or Exceeds 124 Reject The age of the patient identified on the encounter must not contain non-numeric values; or the age must not be populated as 0 or greater than 124 years old Scenario: Munali Mohair, a 27-yr old female was admitted to Petunia Mills General Hospital for an overnight stay due to complications following an outpatient procedure. Petunia Mills submitted a claim to Flowery Lanes Health with Ms. Mohair’s DOB listed as 9/23/1985. Flowery Lanes Health submitted the encounter to the EDS with Ms. Mohair’s DOB listed as 9/23/1885, due to a typographical error. The EDS returned edit 18905 on the MAO-002 report. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 20450 Attending Physician is Sanctioned Reject Submitter must ensure that the attending provider was not suspended or terminated from providing services to Medicare beneficiaries during the time(s) of service indicated on the encounter Scenario: Dr. Jernigan, attending physician at Hospice Hotel, made rounds on 1/4/2013, for fellow physician due to an emergency. Hospice Hotel submitted Dr. Jernigan’s claim to Better Health. Better Health submitted the encounter to the EDS. Dr. Jernigan’s privileges were terminated on 12/20/2012, and he was not authorized to provide services for Hospice patients. Better Health received an MAO-002 report with a reject edit of 20450. 837 Institutional Companion Guide Version 38.0/July 2016 . 72 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 20455 Operating Provider Is Sanctioned Informational Submitter must ensure that the operating provider was not suspended or terminated from providing surgical services to Medicare beneficiaries during the time(s) of service indicated on the encounter Scenario: Dr. Madhatter performed a cholecystectomy at Highway Hospital on 3/12/2013. Highway Hospital submitted an Institutional claim to Providers Health Plan. Providers Health submitted the encounter to the EDS on 5/6/2013. It was discovered that Dr. Madhatter’s operating/surgical privileges were suspended on 3/3/2013. The EDS returned the MAO- 002 report to Providers Health with edit 20455. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 20515 Immunization Dx Must Align with HCPCS Informational Administration of the Hepatitis B Vaccine must include relevant HCPCS codes and ICD-9 diagnosis code V05.3 (ICD- 10 code Z23 once required) or this edit will post Scenario: Elizabeth C.K. is a patient at Baltimore Metro ESRD facility. Elizabeth recently received the Hepatitis B Vaccine. Baltimore Metro ESRD submitted encounter with HCPCS code 90740 but failed to include diagnosis code V05.3. The EDS posted error code 20515 since the required ICD-9 diagnosis code V05.3 was not included in the encounter for the service. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 20520 Invalid Ambulance Pick-up Location Informational Encounters for ambulance services must contain a valid nine (9)-digit ZIP code when revenue code 0540 is used and loop 2300 HI01-02=’A0’. Scenario: Family Health submitted an encounter for ambulance services provided by Monarch Medical Transport, but populated the ambulance pick-up location field (Loop segment 2300 HI01-05) as ‘9999999.98’ (invalid). The EDS will accept the encounter and inform the submitter that a valid ambulance pick up ZIP code is required on all ambulance encounters. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 20525 Multiple Ambulance Pick-up Locations Reject Ambulance encounters cannot be submitted containing multiple iterations of loop 2300 HI01-01=‘BE’ and HI01-02 = ‘A0’ Scenario: Round About Health submitted an encounter for ambulance services provided by Maybach Medical Transport. Round About Health submitted the same ZIP code twice for the pick-up location. The EDS rejected the encounter due to multiple ZIP codes listed for the ambulance pick-up location for one (1) patient on the same day. 837 Institutional Companion Guide Version 38.0/July 2016 . 73 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit	Jul2016_CG_837I_5CR_081016.pdf
Resolution/Prevention 20450 Attending Physician is Sanctioned Reject Submitter must ensure that the attending provider was not suspended or terminated from providing services to Medicare beneficiaries during the time(s) of service indicated on the encounter Scenario: Dr. Jernigan, attending physician at Hospice Hotel, made rounds on 1/4/2013, for fellow physician due to an emergency. Hospice Hotel submitted Dr. Jernigan’s claim to Better Health. Better Health submitted the encounter to the EDS. Dr. Jernigan’s privileges were terminated on 12/20/2012, and he was not authorized to provide services for Hospice patients. Better Health received an MAO-002 report with a reject edit of 20450. 837 Institutional Companion Guide Version 38.0/July 2016 . 72 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 20455 Operating Provider Is Sanctioned Informational Submitter must ensure that the operating provider was not suspended or terminated from providing surgical services to Medicare beneficiaries during the time(s) of service indicated on the encounter Scenario: Dr. Madhatter performed a cholecystectomy at Highway Hospital on 3/12/2013. Highway Hospital submitted an Institutional claim to Providers Health Plan. Providers Health submitted the encounter to the EDS on 5/6/2013. It was discovered that Dr. Madhatter’s operating/surgical privileges were suspended on 3/3/2013. The EDS returned the MAO- 002 report to Providers Health with edit 20455. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 20515 Immunization Dx Must Align with HCPCS Informational Administration of the Hepatitis B Vaccine must include relevant HCPCS codes and ICD-9 diagnosis code V05.3 (ICD- 10 code Z23 once required) or this edit will post Scenario: Elizabeth C.K. is a patient at Baltimore Metro ESRD facility. Elizabeth recently received the Hepatitis B Vaccine. Baltimore Metro ESRD submitted encounter with HCPCS code 90740 but failed to include diagnosis code V05.3. The EDS posted error code 20515 since the required ICD-9 diagnosis code V05.3 was not included in the encounter for the service. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 20520 Invalid Ambulance Pick-up Location Informational Encounters for ambulance services must contain a valid nine (9)-digit ZIP code when revenue code 0540 is used and loop 2300 HI01-02=’A0’. Scenario: Family Health submitted an encounter for ambulance services provided by Monarch Medical Transport, but populated the ambulance pick-up location field (Loop segment 2300 HI01-05) as ‘9999999.98’ (invalid). The EDS will accept the encounter and inform the submitter that a valid ambulance pick up ZIP code is required on all ambulance encounters. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 20525 Multiple Ambulance Pick-up Locations Reject Ambulance encounters cannot be submitted containing multiple iterations of loop 2300 HI01-01=‘BE’ and HI01-02 = ‘A0’ Scenario: Round About Health submitted an encounter for ambulance services provided by Maybach Medical Transport. Round About Health submitted the same ZIP code twice for the pick-up location. The EDS rejected the encounter due to multiple ZIP codes listed for the ambulance pick-up location for one (1) patient on the same day. 837 Institutional Companion Guide Version 38.0/July 2016 . 73 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 27000 Height or Weight Value Exceeds Limit Reject Encounters submitted with TOB 72X Values for A8 and A9 must be submitted in kilograms. For Value Code A8: Weight must not exceed 318.2 Kg (700 lbs.). For Value Code A9: Height must not exceed 228.6 Kg (7ft 6 in) Scenario: Mr. Nestle Parks, a 432 lb. male, was admitted to Mountain Top Memorial Hospital with kidney failure due to ESRD. River Run Health Plan submitted an encounter to the EDS for services provided to Mr. Parks during his stay at Mountain Top Memorial. The encounter contained Mr. Parks’ weight in Loop 2300 HI Value Code A8 segment at 432.0. The encounter was rejected with edit 27000 because the A8 value exceeded the allowable value of 318.2 kg. The encounter should have been submitted with Mr. Parks weight identified as 196.36, because the EDS requires that the measurements be populated in kilograms. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 17257 Rev Code 091X Not Allowed Informational Medicare no longer accepts Revenue Code 910 for Psychiatric/Psychological Services. Ensure that the revenue code submitted for psychiatric services is current and valid. Scenario: Mr. Zane Zany was admitted to Far Side Institution due to severe depression. Way Out There Health Care submitted an encounter on behalf of Far Side Institution populated with revenue code 0910, for services provided to Mr. Zany during his admission from 12/15/2012 to 1/14/2013. The EDPS rejected the encounter submission because, as of October 2003, revenue code 0910 was no longer a valid and acceptable Medicare revenue code. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18730 Invalid Modifier Format Informational Submitter must ensure that the modifier on the encounter is acceptable and valid for EDS submission. Ensure that the format is accurate and the appropriate characters are used. Scenario: Pinky Marvelous was admitted to Check-In Memorial Hospital for a radical mastectomy of her left breast. Check-In Memorial submitted a claim for the surgical procedure to Gallant Health Plan. Gallant Health Plan submitted the encounter to the EDS, populated with CPT 19307, modifier ‘L6’. The EDPS posted edit 18730 because the modifier was not entered accurately. The correct submission should be CPT 19307, modifier ‘LT’. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22015 Number of Days Conflicts With HH Episode Informational Submitter must ensure that the sum of the from and through dates for the episode of care does not exceed 60 days Scenario: Big Bell Home Health submitted a claim to Whamo Health Plan for Home Health services provided to Major Colonel from 2 3/2013 through 4/17/2013. Whamo Health Plan submitted the encounter to the EDS with the ‘from’ and ‘through’ dates of 2/ 3/2013 through 4/ 17/2013 on one (1) service line. The encounter was rejected because the episode of care exceeded the required maximum of 60 days. 837 Institutional Companion Guide Version 38.0/July 2016 . 74 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22095 Encounter Must Be Submitted on 837-P DME Reject If the NPI on the encounter identifies a DME Supplier, the submitter must use the Payer ID of 80887 to indicate the service is for DMEPOS. Note: When the Payer ID must be changed for an encounter submitted to the EDS, MAOs and other entities must first void the original encounter, then submit a new encounter with the correct Payer ID. Scenario: Reach Rehab submitted an encounter for an electric hospital bed provided for Mr. Anton upon his discharge from Meyers Medical Center. Reach Rehab Services submitted the encounter to the EDS using the Institutional payer ID of 80882.The encounter was rejected because, although Mr. Anton was discharged from the hospital and received care that would be submitted on an Institutional encounter, services provided by Reach Rehab were specific to DMEPOS. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22135 Multiple Rev Code 0023 Lines Present Reject TOB 32X Home Health encounters must not contain more than one (1) service line containing revenue code 0023. Only one (1) revenue code is defined for each prospective payment system that requires HIPPS codes. Scenario: Harmony Home Health submitted an encounter with two (2) service lines containing HIPPS codes HBFK2 and HAEJ1. Harmony Home Health submitted separate revenue code 0023 service lines for each HIPPS code service line. The EDS rejected the encounter because revenue code 0023 may not be used more than once on a single Home Health encounter in conjunction with HIPPS codes. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22225 Missing Provider Specific Record Reject Encounter was submitted that contains a provider NPI that is not identified in the EDPS provider tables as a participating Medicare provider. Scenario: Ipse Institutional Hospital submitted an encounter file to the EDS for an inpatient procedure performed by Dr. Wymee using NPI 0000000000. The EDPS rejected the encounter because Dr. Wymee was not identified in the EDS as a participating Medicare provider. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22020 Conflict Between CC and OSC Reject Encounters submitted with condition code=C3 (Partial Approval) must contain Occurrence Span Code (OSC) ‘MO’ to indicate the service dates that were approved. Scenario: Blue Bellman was admitted to The Best Nursing Facility on 3/3/2013 and discharged on 4/26/2013. The Quality Improvement Organization (QIO) reviewed the claim submitted to Service Plus Health Plan by The Besting Nursing Facility and denied service dates from 4/3/2013 through 4/26/2013. Service Plus Health Plan submitted the approved dates of service (DOS) using condition code C3, but did not populate the encounter with the ‘MO’ modifier to indicate that the 3/3/2013 through 4/2/2013 DOS were approved. 837 Institutional Companion Guide Version 38.0/July 2016 . 75 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 21951 No OSC 70 or Covered Days Less Than 3 Informational Skilled Nursing Facility (SNF) encounters submitted using revenue code 0022 and TOB 21X, 22X, or 23X must include the submission of Occurrence Span Code 70 to indicate the dates of a qualifying hospital stay of at least three (3) consecutive days, which qualifies the beneficiary for SNF service. Scenario: Stay With Us Nursing Care submitted a claim to Cornerstone Health Care for Mr. Bobst’s SNF stay from 5/3/2013 through 5/13/2013. Cornerstone Health Care submitted the encounter to the EDS using OSC 70; however, due to a data entry error, the ‘from’ and ‘through’ dates on the encounter were 5/3/2013, indicating a one day service. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 17085 CC 40 Required for Same Day Transfer Reject Encounters submitted with TOB 11X and a patient status code of 02, 03, 05, 50, 51, 61, 62, 63, 65, 66, or 70; and the admission date is equal to the statement covers through date must contain Condition Code 40. Scenario: Wendy Wonder was admitted to Healthy Hospital on the morning of 2/21/2013 for a fall due to hallucinations. Healthy Hospital transferred Ms. Wonder to their inpatient psychiatric unit on the evening of 2/21/2013. Health Hospital submitted Ms. Wonder’s claim to Wholeness Health using a patient status code of 65 (Discharged/ Transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a Hospital) without providing the required Condition Code 40. Wholeness Health adjudicated the claim and submitted the encounter to the EDS. The EDPS rejected the encounter because inpatient hospital encounters populated with patient status code 65 must also contain Condition Code 40 to indicate that Ms. Wonder was admitted and discharged on the same date. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22280 Rev Code 277 Invalid for a HH Reject Home Health encounters cannot be submitted using revenue code 277(Medical/surgical supplies oxygen (take home)). Scenario: Fawn Home submitted a claim to Hulu Health Care for provision of oxygen to Cletus Clapp, using revenue cod 0023 for the home health service and revenue code 277 for the supply service. Hulu Health Care adjudicated the claim and submitted the encounter to the EDS. Home Health received an MAO-002 report rejecting the encounter with edit 22280 because revenue code 277 is not a Medicare acceptable revenue code. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18710 Missing/Invalid POA Indicator Reject Encounter type requires that an indicator of ‘Y’ or ‘N’ for Present on Admission according to NUBC requirements, but the indicator is not populated or is inaccurate for the data provided in the encounter. Scenario: Miss Ames was admitted to Hope Hospital for a stroke and a cerebral infarction with complications on 3/26/2013. She was discharged on 4/5/2013. Hope Hospital submitted a claim to Mount Vios for Miss Ames’ hospital admission. Hope Hospital submitted an encounter to the EDS that did not include the required POA indicator of ‘Y’ due to the diagnoses populated on the encounter. The EDS rejected the encounter with error code 18710. 837 Institutional Companion Guide Version 38.0/July 2016 . 76 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 21925 Swing Bed SNF Conditions Not Met Reject Encounter submitted with TOB 18X or 21X with	Jul2016_CG_837I_5CR_081016.pdf
hospital stay of at least three (3) consecutive days, which qualifies the beneficiary for SNF service. Scenario: Stay With Us Nursing Care submitted a claim to Cornerstone Health Care for Mr. Bobst’s SNF stay from 5/3/2013 through 5/13/2013. Cornerstone Health Care submitted the encounter to the EDS using OSC 70; however, due to a data entry error, the ‘from’ and ‘through’ dates on the encounter were 5/3/2013, indicating a one day service. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 17085 CC 40 Required for Same Day Transfer Reject Encounters submitted with TOB 11X and a patient status code of 02, 03, 05, 50, 51, 61, 62, 63, 65, 66, or 70; and the admission date is equal to the statement covers through date must contain Condition Code 40. Scenario: Wendy Wonder was admitted to Healthy Hospital on the morning of 2/21/2013 for a fall due to hallucinations. Healthy Hospital transferred Ms. Wonder to their inpatient psychiatric unit on the evening of 2/21/2013. Health Hospital submitted Ms. Wonder’s claim to Wholeness Health using a patient status code of 65 (Discharged/ Transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a Hospital) without providing the required Condition Code 40. Wholeness Health adjudicated the claim and submitted the encounter to the EDS. The EDPS rejected the encounter because inpatient hospital encounters populated with patient status code 65 must also contain Condition Code 40 to indicate that Ms. Wonder was admitted and discharged on the same date. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22280 Rev Code 277 Invalid for a HH Reject Home Health encounters cannot be submitted using revenue code 277(Medical/surgical supplies oxygen (take home)). Scenario: Fawn Home submitted a claim to Hulu Health Care for provision of oxygen to Cletus Clapp, using revenue cod 0023 for the home health service and revenue code 277 for the supply service. Hulu Health Care adjudicated the claim and submitted the encounter to the EDS. Home Health received an MAO-002 report rejecting the encounter with edit 22280 because revenue code 277 is not a Medicare acceptable revenue code. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18710 Missing/Invalid POA Indicator Reject Encounter type requires that an indicator of ‘Y’ or ‘N’ for Present on Admission according to NUBC requirements, but the indicator is not populated or is inaccurate for the data provided in the encounter. Scenario: Miss Ames was admitted to Hope Hospital for a stroke and a cerebral infarction with complications on 3/26/2013. She was discharged on 4/5/2013. Hope Hospital submitted a claim to Mount Vios for Miss Ames’ hospital admission. Hope Hospital submitted an encounter to the EDS that did not include the required POA indicator of ‘Y’ due to the diagnoses populated on the encounter. The EDS rejected the encounter with error code 18710. 837 Institutional Companion Guide Version 38.0/July 2016 . 76 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 21925 Swing Bed SNF Conditions Not Met Reject Encounter submitted with TOB 18X or 21X with Revenue Code 0022 and Occurrence Span Code 70 is not present or Occurrence Code 50 is not present for each submission of Revenue Code 0022. Scenario: Riverwalk Rehab, a Skilled Nursing Facility, submitted a claim to Haven Health Care for Mr. Benson’s admission, following his transfer after a ten (10) day stay at Marco General Hospital. Haven Health submitted an encounter to the EDS using TOB 21X, Revenue Code 0022, and the required Occurrence Span Code of ‘70’, which indicated Mr. Bensons’ inpatient hospital stay of three (3) days or greater. The EDS rejected the encounter with error code 21925 because it did not also include the Occurrence Code of ‘50’, which is required for each service line submitted for Revenue Code 0022. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22405 Occurrence Code 55 & DOD Required Reject When patient discharge status code is 20 (expired), 40 (expired at home), 41 (expired in a medical facility), or 42 (expired – place unknown), submitter must ensure that Occurrence Code 55 and the date of death are present. Scenario: Gentle HealthCare submitted a final claim to Monument Medical Health Plan for Mr. G. Barnes, who expired on 9/15/2013. Monument Medical Health submitted and encounter to the EDS with a patient discharge status code of 41 in Loop 2300 CL103, but the Occurrence Code and Date of Death (occurrence code date) were not provided. The EDS rejected the encounter on the MAO-002 Report with error code 22405. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 17100 DOS Required for HH Encounter Reject Home Health encounters submitted with Revenue Codes 42X-44X and 55X-59X must contain dates of service for the revenue code line. Scenario: Tympany Home Health submitted an encounter to the EDS for physical therapy services (Revenue Code 42X) provided during a Home Health episode of care to Mrs. Waterman from 8/3/2013 through 8/31/2013. The encounter was rejected with error code 17100 because, although the dates of service were populated on the encounter header level, the revenue code line did not contain the physical therapy service dates. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00175 Verteporfin Reject Encounters submitted with TOB 13X or 85X for Ocular Photodynamic Tomography with Verteporfin must contain the same dates of service for the combination of these services, with the appropriate ICD-9 and ICD- 10 diagnosis codes. Submitter must also ensure that the procedures are valid for the dates of service. Scenario: Dr. Cuff conducted an OPT with Verteporfin (J3396 and 67225) for Mr. Jay Bird as treatment for Mr. Bird’s diagnosis of atrophic macular degeneration (362.51). The encounter was submitted to the EDS by Strideways Health and rejected because the diagnosis of 362.51 should not be identified for the service submitted on the encounter. 837 Institutional Companion Guide Version 38.0/July 2016 . 77 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00750 Service(s) Not Covered Prior To 4/1/2013 Reject Encounters submitted for Ventricular Assist Devices (VADs) supplies/accessories with procedure code Q0507, Q0508, or Q0509 must contain dates of service on or after 4/01/2013 Scenario: Dr. Zhivago’s office submitted a claim to Healthy Heart Health Plan for a battery and battery charger provided to Mr. Joe Schmeaux following the attachment of his VAD on 2/3/2013. Healthy Heart submitted an encounter to the EDS using Q0507. The EDS rejected the encounter with error code 00750 because Q0507 was not an effective code for DOS prior to 4/1/2013. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22320 Missing ASC Procedure Code Informational The procedure codes present on TOB 83X encounter service lines cannot be located in the ASC Fee Schedule or ASC Drug Fee Schedule. Scenario: Flex Medical ASC submitted a TOB 83X encounter to the EDS with procedure code G0261 (prostate brachytherapy), which is not listed in the ASC Fee Schedule. The EDPS posted error 22320 because procedure code G0261 is not an acceptable procedure code in an ASC setting. TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22340 ESRD Diagnosis Code Missing Reject ERSD encounters (TOB 72X) must use the ESRD-related ICD-9 or ICD-10 diagnosis codes based on DOS (i.e., ICD-9 prior to 10/01/2015; ICD-10 on or after 10/01/2015). Scenario: On 10/15/2015, Health4U submitted an encounter to the EDS with bill type 72X for Feng Li’s consultation with Dr. Jones on 9/1/2015 with ICD-10 diagnosis code N18.2 “Chronic Kidney Disease, Stage 2 (Mild)”. The EDPS rejected the encounter because the DOS submitted on the encounter requires the use of ICD-9 diagnosis codes. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22355 Inpatient Service Line Error Reject EDPS will reject Institutional inpatient encounters (TOB 11X, 18X, 21X, and 41X) at the header level when any of the associated service lines have been rejected. MAOs must correct the service line errors and resubmit the encounter. Scenario: On 6/28/2015, Care Bear Health resubmitted an encounter to the EDS with bill type 21X and a billed amount of $240.00 on the Revenue Code 0022 service line. The EDS previously rejected the encounter and returned an MAO-002 Report containing error code 21979 “Charges for Rev Code 0022 Must Be Zero“ because the Revenue Code service line billed amount and non-covered charge amounts must be either blank or equal to zero. The adjusted encounter received error code 22355 at the header level because it contained a reject error on the service line. 837 Institutional Companion Guide Version 38.0/July 2016 . 78 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22390 HIPPS Code Required for SNF/HH Reject Encounters must contain HIPPS codes when submitted with TOB 18X or 21X and Revenue Code 0022 or TOB 32X and Revenue Code 0023. Note: This edit will post as a reject only for DOS on or after 7/1/2014. Scenario: Lamplight Home Health submitted an encounter to the EDS containing TOB 32X (Home Health – Inpatient), Revenue Code 0023, and procedure code G0154(x2). The encounter did not contain a HIPPS code on the Revenue Code 0023 service line. The EDS returned the encounter with error code 22390, because all Home Health encounters must be submitted with appropriate HIPPS codes. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22395 HIPPS Code Conflicts with Revenue Code Reject Encounters must contain the appropriate HIPPS code for the service submitted. Revenue Code 0022 must contain appropriate SNF HIPPS codes. Revenue Code 0023 must contain appropriate HH HIPPS codes. Note: This edit will post as a reject only for DOS on or after 7/1/2014. Scenario: Pink Lady Nursing Care submitted a claim to Aurelia Health Plan for SNF services provided for Ms. Jamella Fantastic. Aurelia Health Plan submitted the encounter to the EDS with TOB 21X, Revenue Code 0022 and HIPPS code HAEK2. The EDS returned the encounter with error code 22395, because the HIPPS code populated on the encounter indicated a Home Health service instead of a Skilled Nursing Facility service. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22400 HP Qualifier Must Exist for HIPPS Code Reject Encounters submitted with TOB 18X or 21X and Revenue Code 0022 or TOB 32X and Revenue Code 0023 must contain a value of ‘HP’ in the SV202-1 element for HIPPS codes. Note: This edit will post as a reject only for DOS on or after 7/1/2014. Scenario: Serenity Care Nursing submitted a claim to Universal Medical Health Plan for Mr. Bacchus’ two (2) week stay at their Skilled Nursing Facility. Universal Medical Health Plan submitted the encounter to the EDS with the appropriate HIPPS codes; however, the qualifier was populated with ‘HC’ (procedure code qualifier). TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22410 Invalid Service(s) for TOB Reject Encounters submitted for Ventricular Assist Devices (VADs) supplies and accessories with procedure codes must only contain specific bill types (12X, 13X, 22X, 23X, 32X, 33X, 34X, 74X, or 85X). Note: TOB 33X is not applicable on or after 10/1/2013 Scenario: Dr. Pandora submitted a claim to Healthy Heart Health Plan for wound care and dressings provided after Mr. Jingleheimer’s pacemaker insertion. The encounter was submitted to the EDS with TOB 14X. The encounter was rejected with error code 22410, because VAD supplies and accessories cannot be submitted with this bill type. 837 Institutional Companion Guide Version 38.0/July 2016 . 79 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22415 Revenue code 0274 Required Reject Encounters submitted for Ventricular Assist Devices (VADs) supplies/accessories with procedure code Q0507, Q0508, or Q0509 must contain Revenue Code 0274 and the appropriate bill types (12X, 13X, 22X, 23X, 32X, 33X, 34X, 74X, or 85X). Scenario: Karma Health submitted an encounter to the EDS for VAD replacement leads using Revenue Code 0022. The encounter was rejected with error code 22415 because Revenue Code 0274 is the only appropriate code for submission of VAD supplies and accessories. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22420 TOB 33X Invalid for DOS Reject	Jul2016_CG_837I_5CR_081016.pdf
the Revenue Code 0023 service line. The EDS returned the encounter with error code 22390, because all Home Health encounters must be submitted with appropriate HIPPS codes. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22395 HIPPS Code Conflicts with Revenue Code Reject Encounters must contain the appropriate HIPPS code for the service submitted. Revenue Code 0022 must contain appropriate SNF HIPPS codes. Revenue Code 0023 must contain appropriate HH HIPPS codes. Note: This edit will post as a reject only for DOS on or after 7/1/2014. Scenario: Pink Lady Nursing Care submitted a claim to Aurelia Health Plan for SNF services provided for Ms. Jamella Fantastic. Aurelia Health Plan submitted the encounter to the EDS with TOB 21X, Revenue Code 0022 and HIPPS code HAEK2. The EDS returned the encounter with error code 22395, because the HIPPS code populated on the encounter indicated a Home Health service instead of a Skilled Nursing Facility service. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22400 HP Qualifier Must Exist for HIPPS Code Reject Encounters submitted with TOB 18X or 21X and Revenue Code 0022 or TOB 32X and Revenue Code 0023 must contain a value of ‘HP’ in the SV202-1 element for HIPPS codes. Note: This edit will post as a reject only for DOS on or after 7/1/2014. Scenario: Serenity Care Nursing submitted a claim to Universal Medical Health Plan for Mr. Bacchus’ two (2) week stay at their Skilled Nursing Facility. Universal Medical Health Plan submitted the encounter to the EDS with the appropriate HIPPS codes; however, the qualifier was populated with ‘HC’ (procedure code qualifier). TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22410 Invalid Service(s) for TOB Reject Encounters submitted for Ventricular Assist Devices (VADs) supplies and accessories with procedure codes must only contain specific bill types (12X, 13X, 22X, 23X, 32X, 33X, 34X, 74X, or 85X). Note: TOB 33X is not applicable on or after 10/1/2013 Scenario: Dr. Pandora submitted a claim to Healthy Heart Health Plan for wound care and dressings provided after Mr. Jingleheimer’s pacemaker insertion. The encounter was submitted to the EDS with TOB 14X. The encounter was rejected with error code 22410, because VAD supplies and accessories cannot be submitted with this bill type. 837 Institutional Companion Guide Version 38.0/July 2016 . 79 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22415 Revenue code 0274 Required Reject Encounters submitted for Ventricular Assist Devices (VADs) supplies/accessories with procedure code Q0507, Q0508, or Q0509 must contain Revenue Code 0274 and the appropriate bill types (12X, 13X, 22X, 23X, 32X, 33X, 34X, 74X, or 85X). Scenario: Karma Health submitted an encounter to the EDS for VAD replacement leads using Revenue Code 0022. The encounter was rejected with error code 22415 because Revenue Code 0274 is the only appropriate code for submission of VAD supplies and accessories. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22420 TOB 33X Invalid for DOS Reject Encounters submitted with dates of service (DOS) on or after 10/01/2013 must not contain TOB 33X. Scenario: Strong’s Home Care submitted an encounter with TOB 33X (Home Health – Outpatient) to the EDS for Home Health services provided for Mr. V. Triumph from November 3, 2013 through 11/18/2013. The EDS rejected the encounter and returned an MAO-002 report with error code 22420, because TOB 33X was deactivated for all DOS on or after 10/1/2013. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 18500 Multiple CPT/HCPCS for Same Service Informational Encounters cannot be submitted with multiple procedure codes to identify the same service/procedure. Scenario: ProHealth submitted an encounter to the EDS with procedure code 15839 (labiaplasty) performed on Ms. Cross on 11/13/2013. The EDS returned an MAO-002 report to ProHealth with error code 18500 because ProHealth had already submitted another encounter for the same dates of service for Ms. Cross with procedure code 56620 (labiaplasty). Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 20500 Invalid DOS for Rev Code Billed Reject Encounter’s Revenue Code service date must be within the range of the procedure service line DOS when submitting: a)TOB 71X, 75X, or 77X with a valid Revenue Code; b) Revenue Code 054X with TOBs 13X, 22X, 23X, 83X, or 85X; c) Revenue Codes 042X, 43X, 044X, or 047X with TOBs 12X, 13X, 22X, 23X, 74X, or 83X; d) Revenue Code 047X with TOB 34X; or e) Revenue Codes within the range of 0300-0319 with HCPCS Codes 78267, 78268,80002-89399, or G0000- G9999 and TOBs 13X, 14X, 23X, 72X, 83X, or 85X Scenario: Pink Acres Health Clinic submitted a claim to Way Out Health Plan for behavioral health services provided to Cookie Triton from 3/26/2013 through 4/12/2013. Way Out Health Plan submitted an encounter to the EDS with TOB 71X and Revenue Code 0900 with procedure service line DOS of 3/26/15 – 4/12/15 and Revenue Code service dates of 4/26/15 – 5/12/15. The EDS rejected the encounter because the Revenue Code service dates were not valid for the dates of the service provided. 837 Institutional Companion Guide Version 38.0/July 2016 . 80 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 21979 Charges for Rev Code 0022 Must Be Zero Reject For encounters submitted with TOB 18X or 21X and Revenue Code 0022, the billed amount (Loop 2400 SV203) and non- covered charge amount (Loop 2400 SV207) should equal zero when these fields are populated for the Revenue Code service line. Scenario: Mohair Nursing Camp submitted a claim to Fancy Free Health Plan for services provided to Curly Sue Skumptik. Fancy Free Health Plan submitted an encounter for the services to the EDS containing a billed amount of $240.00 on the Revenue Code 0022 service line. The EDS rejected the encounter and returned an MAO-002 Report containing error code 21979 because the Revenue Code service line billed amount and non-covered charge amounts must be either blank or equal to zero. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 98300 Exact Inpatient Duplicate Encounter Reject MAOs must submit replacement or void encounters when altering Inpatient encounters. The EDPS will reject Inpatient encounters submitted with bill types 11X, 18X, 21X, or 41X that contain duplicate header level (loop 2300) data elements for the HICN, DOS, TOB, and Billing Provider NPI of an existing accepted and stored encounter. Scenario: On 8/3/2015, A Fine MAO submitted an encounter for Mayank Deshpande’s stay at Mercy Hospital from 6/15/2015 through 6/23/2015. On 8/10/2015, A Fine MAO resubmitted the same encounter as an original to the EDPS with altered procedure modifiers. The EDPS rejected the encounter submitted on 8/10/2015 because the header level (loop 2300) HICN, DOS, TOB, and Billing Provider NPI data values matched those of the previous encounter submitted on 8/3/2015. If the provider wishes to adjust the line level (loop 2400) elements, they must submit a replacement encounter or void the original encounter then resubmit. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 98315 Linked Chart Review Duplicate Reject Linked Chart Review encounters cannot be submitted where the HICN, Associated ICN, header DOS, diagnosis code(s) and TOB contain the exact same values as another Chart Review encounter already present within the EODS. Scenario: Sequoia Health Plan conducted an audit of Langhorne Hospital and discovered an encounter previously submitted to the EDS contained an unnecessary diagnosis code. On 4/01/2014, Sequoia Health Plan submitted a linked chart review encounter to the EDS containing the associated ICN of the original encounter to identify the unnecessary diagnosis code. On 5/01/2014 Sequoia Health Plan inadvertently submitted the exact same linked chart review encounter to the EDS. The EDS rejected the second submission of the linked chart review encounter because no changes were detected between the two (2) linked chart review encounters. 837 Institutional Companion Guide Version 38.0/July 2016 . 81 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 98320 Chart Review Duplicate Reject Unlinked Chart Review encounters cannot be submitted where the HICN, header DOS, diagnosis code(s) and TOB contain the exact same values as another Chart Review encounter already present within the EODS. Scenario: Ohio Health Plan conducted an audit of Cincinnati City Hospital and discovered an encounter not previously submitted to the EDS required an additional diagnosis code. On 3/15/2014, Ohio Health Plan submitted an unlinked chart review encounter to the EDS to include the additional diagnosis code. On 6/01/2014, Ohio Health Plan submitted the same unlinked chart review encounter to the EDS due to a clerical error. The EDS rejected the second submission of the unlinked chart review encounter because the EDS detected no changes between the two (2) unlinked chart review encounters. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00030 ICD-10 Dx Not Allowed Reject ICD-10 diagnosis and/or procedure codes cannot be submitted for inpatient or home health encounters with ‘Through’ DOS prior to 10/01/2015 or outpatient encounters with a ‘From’ DOS prior to 10/1/2015. ICD-9 codes are required. Scenario: Arthur Home Health submitted an encounter (TOB 32X) for Elizabeth Door with DOS from 11/15/2014 through 11/20/2014 with a primary diagnosis code of C509.19 (Malignant Neoplasm of Unspecified Site). The EDS rejected the encounter because an ICD-10 diagnosis code was reported prior to the established transition date to ICD-10 codes. The encounter must be updated with ICD-9 diagnosis code 174.9 and resubmitted to the EDS. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00035 ICD-9 Dx Not Allowed Reject ICD-9 diagnosis and/or procedure codes cannot be submitted for inpatient or home health encounters with ‘Through’ DOS on or after 10/01/2015 or outpatient encounters with a ‘From’ DOS on or after to 10/1/2015. ICD- 10 codes are required. Scenario: Arthur Home Health submitted an encounter (TOB 32X) for Elizabeth Door with DOS from 12/03/2015 through 12/10/2015 with a primary diagnosis code of 174.9 (Malignant Neoplasm of Breast (Female) Unspecified Site). The EDS rejected the encounter because an ICD-9 diagnosis code was reported after the established transition date to ICD-10 codes. The encounter must be updated with ICD-10 diagnosis code C509.19 and resubmitted to the EDS. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00775 Unable to Adjust Rejected Encounter Reject MAOs cannot submit a replacement encounter that links to a rejected encounter stored in the EODS. Scenario: Torchlight Healthcare submitted an encounter for services provided to James Miramar by Dr. Gavin, and received ICN 5555555555552. The EDPS rejected the encounter due to invalid beneficiary information. Dr. Gavin’s staff identified the need to adjust the payment amount, and sent the corrected payment information to Torchlight Healthcare. Torchlight Healthcare submitted the replacement encounter, containing the corrected payment amount, to the EDPS prior to reconciling the MAO-002 report that identified the original encounter as a rejected encounter. The EDPS rejected the replacement encounter because the original encounter stored in the EODS with ICN 5555555555552 had been rejected. 837 Institutional Companion Guide Version 38.0/July 2016 . 82 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00780 Adjustment Must Match Original Reject When submitting a replacement or void encounter, MAOs must match the ICN, HICN, Last Name, First Name, Payer ID, and TOB header data elements of an accepted encounter stored in the EODS. Note: The EDPS will validate the beneficiary’s demographic data (HICN, Last Name, First Name) according to the Medicare Beneficiary Database (MBD), as well as validate the beneficiary’s Billing Provider NPI prior to posting edit 00780 Scenario: Torchlight Healthcare submitted an encounter totaling $250 for services provided to Ciao Bella by Grammar City Hospital, and received ICN 5555555555557. Grammar City Hospital resubmitted the encounter to correct the payment amount to $205, to Torchlight Healthcare under a new Payer ID. Torchlight Healthcare submitted the replacement encounter to the EDPS with the corrected payment information and the patient’s new Payer ID. The EDPS rejected the replacement encounter because the patient’s Payer ID did not match that of the stored encounter in the EODS or the MBD. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00785 Linked Encounter Not in EODS Reject The ICN referenced in a linked chart review	Jul2016_CG_837I_5CR_081016.pdf
through 11/20/2014 with a primary diagnosis code of C509.19 (Malignant Neoplasm of Unspecified Site). The EDS rejected the encounter because an ICD-10 diagnosis code was reported prior to the established transition date to ICD-10 codes. The encounter must be updated with ICD-9 diagnosis code 174.9 and resubmitted to the EDS. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00035 ICD-9 Dx Not Allowed Reject ICD-9 diagnosis and/or procedure codes cannot be submitted for inpatient or home health encounters with ‘Through’ DOS on or after 10/01/2015 or outpatient encounters with a ‘From’ DOS on or after to 10/1/2015. ICD- 10 codes are required. Scenario: Arthur Home Health submitted an encounter (TOB 32X) for Elizabeth Door with DOS from 12/03/2015 through 12/10/2015 with a primary diagnosis code of 174.9 (Malignant Neoplasm of Breast (Female) Unspecified Site). The EDS rejected the encounter because an ICD-9 diagnosis code was reported after the established transition date to ICD-10 codes. The encounter must be updated with ICD-10 diagnosis code C509.19 and resubmitted to the EDS. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00775 Unable to Adjust Rejected Encounter Reject MAOs cannot submit a replacement encounter that links to a rejected encounter stored in the EODS. Scenario: Torchlight Healthcare submitted an encounter for services provided to James Miramar by Dr. Gavin, and received ICN 5555555555552. The EDPS rejected the encounter due to invalid beneficiary information. Dr. Gavin’s staff identified the need to adjust the payment amount, and sent the corrected payment information to Torchlight Healthcare. Torchlight Healthcare submitted the replacement encounter, containing the corrected payment amount, to the EDPS prior to reconciling the MAO-002 report that identified the original encounter as a rejected encounter. The EDPS rejected the replacement encounter because the original encounter stored in the EODS with ICN 5555555555552 had been rejected. 837 Institutional Companion Guide Version 38.0/July 2016 . 82 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00780 Adjustment Must Match Original Reject When submitting a replacement or void encounter, MAOs must match the ICN, HICN, Last Name, First Name, Payer ID, and TOB header data elements of an accepted encounter stored in the EODS. Note: The EDPS will validate the beneficiary’s demographic data (HICN, Last Name, First Name) according to the Medicare Beneficiary Database (MBD), as well as validate the beneficiary’s Billing Provider NPI prior to posting edit 00780 Scenario: Torchlight Healthcare submitted an encounter totaling $250 for services provided to Ciao Bella by Grammar City Hospital, and received ICN 5555555555557. Grammar City Hospital resubmitted the encounter to correct the payment amount to $205, to Torchlight Healthcare under a new Payer ID. Torchlight Healthcare submitted the replacement encounter to the EDPS with the corrected payment information and the patient’s new Payer ID. The EDPS rejected the replacement encounter because the patient’s Payer ID did not match that of the stored encounter in the EODS or the MBD. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00785 Linked Encounter Not in EODS Reject The ICN referenced in a linked chart review must match the ICN of an accepted encounter stored in the EODS. Scenario: ABC Health Plan submitted an encounter for Janice Wei, and received ICN 1231234564569. As a result of a routine medical record review 6 months later, ABC Health Plan submitted a linked chart review encounter referencing ICN 1231234564568 to add a diagnosis code. The EDPS rejected the chart review encounter because there was not an existing, accepted encounter with ICN 1231234564568 stored in the EODS. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00790 Linked Encounter is Voided/Adjusted Reject The ICN referenced in a linked chart review must not match the ICN of a voided encounter stored in the EODS. Scenario: ABC Health Plan submitted an encounter for Emanuel Spice, and received ICN 1234567890123. ABC Health Plan discovered the encounter was submitted in error and submitted a void request to the EDS three months following the original submission. After a chart audit a year later, ABC Health Plan submitted a linked chart review encounter referencing ICN 1234567890123 to delete an incorrectly reported diagnosis code. The EDPS rejected the chart review encounter because the encounter stored in the EODS with ICN 1234567890123 was voided. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00795 Linked Encounter is Rejected Reject The ICN referenced in a linked chart review must not match the ICN of a rejected encounter stored in the EODS. Scenario: ABC Health Plan submitted an encounter for Shaunna Brookstone, and received ICN 4561234561232. The EDPS rejected the encounter due to invalid beneficiary information populated on the encounter. As a result of a routine medical record review a year later, ABC Health Plan submitted a linked chart review encounter referencing ICN 4561234561232 to add diagnoses. The EDPS rejected the chart review encounter because the encounter stored in the EODS with ICN 4561234561232 was rejected. 837 Institutional Companion Guide Version 38.0/July 2016 . 83 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 03015 HCPCS Code Invalid for DOS Reject Prior to encounter submission, the submitter should verify that the procedure code is valid/effective for the DOS populated on the encounter. Scenario: Oxford Hospital submits an encounter on 3/01/2013 for Chance Borny for a DOS 2/17/2013 which included HCPCS code G0290. The EDS will report error code 03015 with a “reject” status on the MAO-002 report because HCPCS code G0290 was terminated 12/31/2012. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 03022 Invalid CMG for IRF Encounter Reject TOB 11X Inpatient Rehabilitation Facility encounter service lines billed with Revenue Code 0024 must contain acceptable HIPPS codes. Scenario: Duane Max suffered a minor stroke and is recovering at Summer Rehab Facility. Summer Rehab submitted a TOB 11X encounter with a service line containing Revenue Code 0024 and HIPPS code 1BFLS. The EDPS posted edit 03022 since HIPPS code 1BFLS is invalid and A0101 (Stroke with Motor >51.05 w/o comorbidities) should have been entered on the service line containing Revenue Code 0024, based on the HIPPS assessment performed. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 03102 Invalid Provider Type/Specialty Informational The EDPS derives the Provider Specialty based on Provider’s Address. Ensure the correct Provider Address is included on the encounter relevant to the services rendered. Scenario: Revive Center is an Independent Diagnostic Testing Center (provider specialty code 47) that contains a Mammography Screening Center (provider specialty code 45). Routine diagnostic tests were performed on Mr. Keene; however, the tests were billed under the location address for Provider Specialty code 45 rather than 47. The EDPS will post error code 03102 for this encounter due to the use of the wrong specialty code on the encounter. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 03165 Telehealth Facility Fee Not Allowed Reject Institutional Telehealth encounter service lines containing procedure code Q3014 (Telehealth Originating Site Facility Fee) must include revenue code 078X (telemedicine) and one (1) of the following bill types: 12X, 13X, 22X, 23X, 71X, 72X, 76X, 77X, or 85X. Scenario: Dr. Smith, working through Century Hospital, used the Telehealth option to follow-up with patient Saqib Murray. Dr. Smith submitted a Telehealth encounter service line with procedure code Q3014, revenue code 0780, and bill type 11X to the MAO, 4YourHealth. 4YourHealth submitted the encounter to the EDS. The EDPS rejected the service line because bill type 11X is not an accepted bill type for the Telehealth Originating Site Fee. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 20495 Revenue Code Is Non-Billable for TOB Reject Encounters with TOB 22X with certain revenue codes will receive this edit. Scenario: Skilled Nursing Facility Summit Peak submits a TOB 22X encounter incorrectly containing a service with revenue code 0944 – Drug Rehabilitation. The EDS will report error code 20495 because revenue code 0944 is not permitted on TOB 22X encounters. 837 Institutional Companion Guide Version 38.0/July 2016 . 84 TABLE 18 – EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED) Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22430 HCPCS Codes with Invalid TOB Reject Encounters with TOB 22X or 23X billed with the following HCPCS codes will receive this edit: G0446, G0442, G0443, G0444, and G0447. Scenario: Skilled Nursing Facility Summit Peak submits a TOB 22X encounter incorrectly containing a service with HCPCS code G0442 – Annual Alcohol Misuse Screening – 15 Minutes. The EDS will report error code 22430 because HCPCS code G0442 is not permitted on TOB 22X or 23X encounters. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 22375 Item/Service Not Covered For RHC” Reject All FQHC encounter service lines must contain only qualified FQHC services. Scenario: Top Care Health Plan submits a TOB 71X encounter incorrectly containing a service with revenue code 030X (Lab). The EDS will reject this encounter with error code 22375 because revenue code 030X is not permitted for submission in conjunction with TOB 71X. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00800 Parent ICN Not Allowed for Original Reject An original, non-chart review encounter should not contain a a linked ICN. Scenario: Southwest Health Plan submitted an original, non-chart review encounter for Samuel Anderson. The original, non-chart review encounter contained a reference to ICN 4561234561233. The EDPS rejected the encounter because an original, non-chart review encounter should not contain an ICN. The original encounter should be resubmitted without the ICN. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00805 Deleted Diagnosis Code Not Allowed Reject An unlinked chart review encounter should not be submitted with an indicator for deleting diagnosis code(s). OR A replacement chart review encounter for a previously accepted unlinked chart review encounter should not be submitted with an indicator for deleting diagnosis code(s). Scenario 1: Southwest Health Plan submitted an unlinked chart review encounter (i.e., a chart review encounter without an ICN reference). The original unlinked chart review contains the indicator for deleting a diagnosis code (REF01 = ‘EA’/REF02 = ‘8’). The EDPS rejected the original, unlinked chart review encounter because no reference to an existing diagnosis code exists for deletion. Scenario 2: Southwest Health Plan submitted a replacement chart review encounter (frequency code ‘7’) for a previously accepted unlinked chart review encounter (i.e., a chart review encounter without an ICN reference). The replacement chart review encounter includes an indicator for deleting a diagnosis code (REF01=’EA’/REF 03 = ‘8’). The EDPS rejected the replacement chart review encounter because EDPS does not allow deletion of a diagnosis from an unlinked chart review. To delete a diagnosis code from an unlinked chart review, the plan should void the existing unlinked chart review and resubmit without the diagnosis code. 837 Institutional Companion Guide Version 38.0/July 2016 . 85 11.0 Submission of Default Data in a Limited Set of Circumstances MAOs and other entities may submit default data in a limited set of circumstances, as identified and explained in Table 19. MAOs and other entities cannot submit default data for any circumstances other than those listed in the table below. CMS will use this interim approach for the submission of encounter data. In each circumstance where default information is submitted, MAOs and other entities are required to indicate in Loop 2300, NTE01=’ADD’, NTE02 = the reason for the use of default information. If there are any questions regarding appropriate submission of default encounter data, MAOs and other entities should contact CMS for clarification. CMS will provide additional guidance concerning default data, as necessary. 11.1 Default Data Reason Codes (DDRC) Loop 2300, NTE02 allows for a maximum of 80 characters and one (1) iteration, which limits the submission of default data to one (1) message per encounter. In order to allow the population of multiple default data messages in the NTE02 field, CMS will use a three (3)-digit default data reason code (DDRC), which will map to the full default data message in the EDS. MAOs and other entities may submit multiple DDRCs with the appropriate three (3)-digit DDRC. Multiple DDRCs will be populated in a stringed sequence with no spaces or separators between each DDRC (i.e., 036040048). Table 19 provides the CMS approved situations for use of default data, the default data message, and the default data reason code. TABLE 19 – DEFAULT DATA *DEFAULT DATA DEFAULT DATA MESSAGE (NTE02)	Jul2016_CG_837I_5CR_081016.pdf
review encounter contained a reference to ICN 4561234561233. The EDPS rejected the encounter because an original, non-chart review encounter should not contain an ICN. The original encounter should be resubmitted without the ICN. Edit # Edit Description Edit Disposition Comprehensive Resolution/Prevention 00805 Deleted Diagnosis Code Not Allowed Reject An unlinked chart review encounter should not be submitted with an indicator for deleting diagnosis code(s). OR A replacement chart review encounter for a previously accepted unlinked chart review encounter should not be submitted with an indicator for deleting diagnosis code(s). Scenario 1: Southwest Health Plan submitted an unlinked chart review encounter (i.e., a chart review encounter without an ICN reference). The original unlinked chart review contains the indicator for deleting a diagnosis code (REF01 = ‘EA’/REF02 = ‘8’). The EDPS rejected the original, unlinked chart review encounter because no reference to an existing diagnosis code exists for deletion. Scenario 2: Southwest Health Plan submitted a replacement chart review encounter (frequency code ‘7’) for a previously accepted unlinked chart review encounter (i.e., a chart review encounter without an ICN reference). The replacement chart review encounter includes an indicator for deleting a diagnosis code (REF01=’EA’/REF 03 = ‘8’). The EDPS rejected the replacement chart review encounter because EDPS does not allow deletion of a diagnosis from an unlinked chart review. To delete a diagnosis code from an unlinked chart review, the plan should void the existing unlinked chart review and resubmit without the diagnosis code. 837 Institutional Companion Guide Version 38.0/July 2016 . 85 11.0 Submission of Default Data in a Limited Set of Circumstances MAOs and other entities may submit default data in a limited set of circumstances, as identified and explained in Table 19. MAOs and other entities cannot submit default data for any circumstances other than those listed in the table below. CMS will use this interim approach for the submission of encounter data. In each circumstance where default information is submitted, MAOs and other entities are required to indicate in Loop 2300, NTE01=’ADD’, NTE02 = the reason for the use of default information. If there are any questions regarding appropriate submission of default encounter data, MAOs and other entities should contact CMS for clarification. CMS will provide additional guidance concerning default data, as necessary. 11.1 Default Data Reason Codes (DDRC) Loop 2300, NTE02 allows for a maximum of 80 characters and one (1) iteration, which limits the submission of default data to one (1) message per encounter. In order to allow the population of multiple default data messages in the NTE02 field, CMS will use a three (3)-digit default data reason code (DDRC), which will map to the full default data message in the EDS. MAOs and other entities may submit multiple DDRCs with the appropriate three (3)-digit DDRC. Multiple DDRCs will be populated in a stringed sequence with no spaces or separators between each DDRC (i.e., 036040048). Table 19 provides the CMS approved situations for use of default data, the default data message, and the default data reason code. TABLE 19 – DEFAULT DATA DEFAULT DATA DEFAULT DATA MESSAGE (NTE02) DEFAULT DATA REASON CODE Rejected Line Extraction REJECTED LINES CLAIM CHANGE DUE TO REJECTED LINE EXTRACTION 036 Medicaid Service Line Extraction MEDICAID CLAIM CHANGE DUE TO MEDICAID SERVICE LINE EXTRACTION 040 EDS Acceptable Anesthesia Modifier MODIFIER CLAIM CHANGE DUE TO EDS ACCEPTABLE ANESTHESIA MODIFIER 044 Default NPI for atypical providers NO NPI ON PROVIDER CLAIM 048 Default EIN for atypical providers** NO EIN ON PROVIDER CLAIM 052 Chart Review Default Procedure Codes DEFAULT PROCEDURE CODES INCLUDED IN CHART REVIEW 056 True COB Default Adjudication Date DEFAULT TRUE COB PAYMENT ADJUDICATION DATE 060 Default NPIs should only be submitted to the EDS when the provider is considered “atypical.” An atypical provider is defined as an individual or business that bills for services rendered but does not meet the definition of a healthcare provider according to the NPI Final Rule 45 CFR 160.103 (e.g., non- emergency transportation providers, Meals on Wheels, personal care services, etc.). *Default EIN should only be submitted to the EDS when the provider is considered “atypical.” 837 Institutional Companion Guide Version 38.0/July 2016 . 86 12.0 Tier II Testing CMS developed the Tier II testing environment to ensure that MAOs and other entities have the opportunity to test a more inclusive sampling of their data. MAOs and other entities that have obtained end-to-end certification may submit Tier II testing data. CMS encourages MAOs and other entities to utilize the Tier II testing environment when they have questions or issues regarding edits received on EDFES Acknowledgement Reports or MAO-002 Encounter Data Processing Status reports; and when they have new submission scenarios that they wish to test prior to submitting to production. MAOs and other entities may submit chart review, replacement or void encounters to the Tier II testing environment only when the encounters are linked to previously submitted and accepted encounters in the Tier II testing environment. Encounter files submitted to the Tier II testing environment must comply with the TR3, CMS 5010 Edits Spreadsheets, and the CMS EDS Companion Guides, as well as the following requirements: • • • • • • Files must be identified using the Authorization Information Qualifier data element “Additional Data Identification” in the ISA segment (ISA01= 03). Files must be identified using the Authorization Information data element to identify the “Tier II indicator” in the ISA segment (ISA02= 8888888888). Files must be identified as “Test” in the ISA segment (ISA15=T). Submitters may send multiple Contract IDs per file Submitters may send multiple files for a Contract ID, as long as each file does not exceed 2,000 encounters per Contract ID If any Contract ID on a given file exceeds 2,000 encounters during the processing of the file, the entire file will be returned As with production encounter data, MAOs and other entities will receive the TA1, 999, and 277CA Acknowledgement Reports and the MAO-002 Reports. While not required, MAOs and other entities are strongly encouraged to correct errors identified on the reports and resubmit data. 837 Institutional Companion Guide Version 38.0/July 2016 . 87 13.0 EDS Acronyms Table 20 below outlines a list of acronyms that are currently used in EDS documentation, materials, and reports distributed to MAOs and other entities. This list is not all-inclusive and should be considered a living document; as acronyms will be added, as required. TABLE 20 – EDS ACRONYMS ACRONYM DEFINITION A N/A ASC Ambulatory Surgery Center C N/A CAH Critical Access Hospital CARC Claim Adjustment Reason Code CAS Claim Adjustment Segments CC Condition Code CCI Correct Coding Initiative CCN Claim Control Number CEM Common Edits and Enhancements Module CMG Case Mix Group CMS Centers for Medicare & Medicaid Services CORF Comprehensive Outpatient Rehabilitation Facility CPO Care Plan Oversight CPT Current Procedural Terminology CRNA Certified Registered Nurse Anesthetist CSC Claim Status Code CSCC Claim Status Category Code CSSC Customer Service and Support Center D N/A DCN Document Control Number DDRC Default Data Reason Code DME Durable Medical Equipment DMEPOS Durable Medical Equipment, Prosthetics, Orthotics, and Supplies DMERC Durable Medical Equipment Carrier DOB Date of Birth DOD Date of Death DOS Date(s) of Service E N/A E & M or E/M Evaluation and Management EDDPPS Encounter Data DME Processing and Pricing Sub-System EDFES Encounter Data Front-End System EDI Electronic Data Interchange EDIPPS Encounter Data Institutional Processing and Pricing Sub-System EDPPPS Encounter Data Professional Processing and Pricing Sub-System EDPS Encounter Data Processing System EDR Encounter Data Record 837 Institutional Companion Guide Version 38.0/July 2016 . 88 ACRONYM DEFINITION EDS Encounter Data System EIC Entity Identifier Code EODS Encounter Operational Data Store ESRD End Stage Renal Disease F N/A FFS Fee-for-Service FQHC Federally Qualified Health Center FTP File Transfer Protocol FY Fiscal Year H N/A HCPCS Healthcare Common Procedure Coding System HHA Home Health Agency HICN Health Information Claim Number HIPAA Health Insurance Portability and Accountability Act HIPPS Health Insurance Prospective Payment System I N/A ICD-9CM/ICD-10CM International Classification of Diseases, Clinical Modification (versions 9 and 10) ICN Interchange Control Number / Internal Control Number IG Implementation Guide IPPS Inpatient Prospective Payment System IRF Inpatient Rehabilitation Facility M N/A MAC Medicare Administrative Contractor MAO Medicare Advantage Organization MTP Multiple Technical Procedure MUE Medically Unlikely Edits N N/A NCD National Coverage Determination NDC National Drug Codes NPI National Provider Identifier NCCI National Correct Coding Initiative NOC Not Otherwise Classified NPPES National Plan and Provider Enumeration System O N/A OASIS Outcome and Assessment Information Set OBRA Omnibus Budget Reconciliation Act of 1993 OCE Outpatient Code Editor OIG Officer of Inspector General OPPS Outpatient Prospective Payment System P N/A PACE Programs of All-Inclusive Care for the Elderly PHI Protected Health Information PIP Periodic Interim Payment 837 Institutional Companion Guide Version 38.0/July 2016 . 89 ACRONYM DEFINITION POA Present on Admission POS Place of Service PPS Prospective Payment System R N/A RAP Request for Anticipated Payment RHC Rural Health Clinic RNHCI Religious Nonmedical Health Care Institution RPCH Regional Primary Care Hospital S N/A SME Subject Matter Expert SNF Skilled Nursing Facility SSA Social Security Administration T N/A TARSC Technical Assistance Registration Service Center TCN Transaction Control Number TOB Type of Bill TOS Type of Service TPS Third Party Submitter V N/A VC Value Code Z N/A ZIP Code Zone Improvement Plan Code 837 Institutional Companion Guide Version 38.0/July 2016 . 90 TABLE 21 - REVISION HISTORY VERSION DATE DESCRIPTION OF REVISION 2.1 9/9/2011 Baseline Version 3.0 11/16/2011 Release 2 4.0 12/9/2011 Release 3 5.0 12/20/2011 Release 4 6.0 3/8/2012 Release 5 7.0 5/9/2012 Release 6 8.0 6/22/2012 Release 7 9.0 8/31/2012 Release 8 10.0 9/26/2012 Release 9 11.0 11/2/2012 Release 10 12.0 11/26/2012 Release 11 13.0 12/21/2012 Release 12 14.0 1/21/2013 Release 13 15.0 2/26/2013 Release 14 16.0 3/20/2013 Release 15 17.0 4/15/2013 Release 16 18.0 5/20/2013 Release 17 19.0 6/24/2013 Release 18 20.0 7/25/2013 Release 19 21.0 9/26/2013 Release 20 22.0 10/25/2013 Release 21 23.0 11/22/2013 Release 22 24.0 12/27/2013 Release 23 25.0 1/20/2014 Release 24 26.0 2/21/2014 Release 25 27.0 3/18/2014 Release 26 28.0 4/28/2014 Release 27 837 Institutional Companion Guide Version 38.0/July 2016 . 91 VERSION DATE DESCRIPTION OF REVISION 29.0 5/30/2014 Release 28 30.0 7/30/2014 Release 29 31.0 9/30/2014 Release 30 32.0 11/28/2014 Release 31 33.0 3/31/2015 Release 32 34.0 6/1/2015 Release 33 35.0 9/4/2015 Release 34 36.0 11/28/2015 Release 35 37.0 3/25/2016 Release 36 38.0 7/8/16 Section 3.1 – Removed Limitations in Connectivity Table 38.0 7/8/16 Section 6.7, Table 10 – Added new EDFES notification 38.0 7/8/16 Section 7.0, Table 11 – Added new deactivated EDFES edit 38.0 7/8/16 Section 10.0, Table 14 – Updated to include new edits (00800, 00805, and 22375). Updated disposition for error code 18730 to informational. 38.0 7/8/16 Section 10.0, Table 15 – Updated to include new edits (00800,00805, 18730, and 22375). 38.0 7/8/16 Section 10.2.3, Table 17 – Updated EDPPPS Edits Prevention and Resolution Strategies to include scenarios for new edits (00800, 00805 and 22375).	Jul2016_CG_837I_5CR_081016.pdf
Improvement Plan Code 837 Institutional Companion Guide Version 38.0/July 2016 . 90 TABLE 21 - REVISION HISTORY VERSION DATE DESCRIPTION OF REVISION 2.1 9/9/2011 Baseline Version 3.0 11/16/2011 Release 2 4.0 12/9/2011 Release 3 5.0 12/20/2011 Release 4 6.0 3/8/2012 Release 5 7.0 5/9/2012 Release 6 8.0 6/22/2012 Release 7 9.0 8/31/2012 Release 8 10.0 9/26/2012 Release 9 11.0 11/2/2012 Release 10 12.0 11/26/2012 Release 11 13.0 12/21/2012 Release 12 14.0 1/21/2013 Release 13 15.0 2/26/2013 Release 14 16.0 3/20/2013 Release 15 17.0 4/15/2013 Release 16 18.0 5/20/2013 Release 17 19.0 6/24/2013 Release 18 20.0 7/25/2013 Release 19 21.0 9/26/2013 Release 20 22.0 10/25/2013 Release 21 23.0 11/22/2013 Release 22 24.0 12/27/2013 Release 23 25.0 1/20/2014 Release 24 26.0 2/21/2014 Release 25 27.0 3/18/2014 Release 26 28.0 4/28/2014 Release 27 837 Institutional Companion Guide Version 38.0/July 2016 . 91 VERSION DATE DESCRIPTION OF REVISION 29.0 5/30/2014 Release 28 30.0 7/30/2014 Release 29 31.0 9/30/2014 Release 30 32.0 11/28/2014 Release 31 33.0 3/31/2015 Release 32 34.0 6/1/2015 Release 33 35.0 9/4/2015 Release 34 36.0 11/28/2015 Release 35 37.0 3/25/2016 Release 36 38.0 7/8/16 Section 3.1 – Removed Limitations in Connectivity Table 38.0 7/8/16 Section 6.7, Table 10 – Added new EDFES notification 38.0 7/8/16 Section 7.0, Table 11 – Added new deactivated EDFES edit 38.0 7/8/16 Section 10.0, Table 14 – Updated to include new edits (00800, 00805, and 22375). Updated disposition for error code 18730 to informational. 38.0 7/8/16 Section 10.0, Table 15 – Updated to include new edits (00800,00805, 18730, and 22375). 38.0 7/8/16 Section 10.2.3, Table 17 – Updated EDPPPS Edits Prevention and Resolution Strategies to include scenarios for new edits (00800, 00805 and 22375).	Jul2016_CG_837I_5CR_081016.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 837 Health Care Claim: Institutional (X223A3) X12 Release 5010 Revised May 24, 2023 Go to Stedi Network This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Transaction Set (837) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment. For purposes of this standard, providers of health care products or services may include entities such as physicians, hospitals and other medical facilities or suppliers, dentists, and pharmacies, and entities providing medical information to meet regulatory requirements. The payer refers to a third party entity that pays claims or administers the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups. A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific health care/insurance industry segment. Delimiters ~ Segment * Element > Component ^ Repetition 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 1/579 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-institutional- x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX POWERED BY Build EDI implementation guides at stedi.com 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 2/579 Overview ISA - Interchange Control Header Max use 1 Required GS - Functional Group Header Max use 1 Required Heading ST 0050 Transaction Set Header Max use 1 Required BHT 0100 Beginning of Hierarchical Transaction Max use 1 Required Submitter Name Loop NM1 0200 Submitter Name Max use 1 Required PER 0450 Submitter EDI Contact Information Max use 2 Required Receiver Name Loop NM1 0200 Receiver Name Max use 1 Required Detail Billing Provider Hierarchical Level Loop HL 0010 Hierarchical Level Max use 1 Required PRV 0030 Billing Provider Specialty Information Max use 1 Optional CUR 0100 Foreign Currency Information Max use 1 Optional Billing Provider Name Loop NM1 0150 Billing Provider Name Max use 1 Required N3 0250 Billing Provider Address Max use 1 Required N4 0300 Billing Provider City, State, ZIP Code Max use 1 Required REF 0350 Billing Provider Tax Identification Max use 1 Required PER 0400 Billing Provider Contact Information Max use 2 Optional Pay-to Address Name Loop NM1 0150 Pay-to Address Name Max use 1 Required N3 0250 Pay-to Address - ADDRESS Max use 1 Required N4 0300 Pay-To Address City, State, ZIP Code Max use 1 Required Pay-To Plan Name Loop 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 3/579 NM1 0150 Pay-To Plan Name Max use 1 Required N3 0250 Pay-to Plan Address Max use 1 Required N4 0300 Pay-To Plan City, State, ZIP Code Max use 1 Required REF 0350 Pay-to Plan Secondary Identification Max use 1 Optional REF 0350 Pay-To Plan Tax Identification Number Max use 1 Required Subscriber Hierarchical Level Loop HL 0010 Hierarchical Level Max use 1 Required SBR 0050 Subscriber Information Max use 1 Required Subscriber Name Loop NM1 0150 Subscriber Name Max use 1 Required N3 0250 Subscriber Address Max use 1 Optional N4 0300 Subscriber City, State, ZIP Code Max use 1 Optional DMG 0320 Subscriber Demographic Information Max use 1 Optional REF 0350 Property and Casualty Claim Number Max use 1 Optional REF 0350 Subscriber Secondary Identification Max use 1 Optional Payer Name Loop NM1 0150 Payer Name Max use 1 Required N3 0250 Payer Address Max use 1 Optional N4 0300 Payer City, State, ZIP Code Max use 1 Optional REF 0350 Billing Provider Secondary Identification Max use 1 Optional REF 0350 Payer Secondary Identification Max use 3 Optional Claim Information Loop CLM 1300 Claim Information Max use 1 Required DTP 1350 Admission Date/Hour Max use 1 Optional DTP 1350 Date - Repricer Received Date Max use 1 Optional DTP 1350 Discharge Hour Max use 1 Optional DTP 1350 Statement Dates Max use 1 Required CL1 1400 Institutional Claim Code Max use 1 Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 4/579 PWK 1550 Claim Supplemental Information Max use 10 Optional CN1 1600 Contract Information Max use 1 Optional AMT 1750 Patient Estimated Amount Due Max use 1 Optional REF 1800 Adjusted Repriced Claim Number Max use 1 Optional REF 1800 Auto Accident State Max use 1 Optional REF 1800 Claim Identifier For Transmission Intermediaries Max use 1 Optional REF 1800 Demonstration Project Identifier Max use 1 Optional REF 1800 Investigational Device Exemption Number Max use 5 Optional REF 1800 Medical Record Number Max use 1 Optional REF 1800 Payer Claim Control Number Max use 1 Optional REF 1800 Peer Review Organization (PRO) Approval Number Max use 1 Optional REF 1800 Prior Authorization Max use 1 Optional REF 1800 Referral Number Max use 1 Optional REF 1800 Repriced Claim Number Max use 1 Optional REF 1800 Service Authorization Exception Code Max use 1 Optional K3 1850 File Information Max use 10 Optional NTE 1900 Billing Note Max use 1 Optional NTE 1900 Claim Note Max use 10 Optional CRC 2200 EPSDT Referral Max use 1 Optional HI 2310 Admitting Diagnosis Max use 1 Optional HI 2310 Condition Information Max use 2 Optional HI 2310 Diagnosis Related Group (DRG) Information Max use 1 Optional HI 2310 External Cause of Injury Max use 1 Optional HI 2310 Occurrence Information Max use 2 Optional HI 2310 Occurrence Span Information Max use 2 Optional HI 2310 Other Diagnosis Information Max use 2 Optional HI 2310 Other Procedure Information Max use 2 Optional HI 2310 Patient's Reason For Visit Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 5/579 HI 2310 Principal Diagnosis Max use 1 Required HI 2310 Principal Procedure Information Max use 1 Optional HI 2310 Treatment Code Information Max use 2 Optional HI 2310 Value Information Max use 2 Optional HCP 2410 Claim Pricing/Repricing Information Max use 1 Optional Attending Provider Name Loop NM1 2500 Attending Provider Name Max use 1 Required PRV 2550 Attending Provider Specialty Information Max use 1 Optional REF 2710 Attending Provider Secondary Identification Max use 4 Optional Operating Physician Name Loop NM1 2500 Operating Physician Name Max use 1 Required REF 2710 Operating Physician Secondary Identification Max use 4 Optional Other Operating Physician Name Loop NM1 2500 Other Operating Physician Name Max use 1 Required REF 2710 Other Operating Physician Secondary Identification Max use 4 Optional Rendering Provider Name Loop NM1 2500 Rendering Provider Name Max use 1 Required REF 2710 Rendering Provider Secondary Identification Max use 4 Optional Service Facility Location Name Loop NM1 2500 Service Facility Location Name Max use 1 Required N3 2650 Service Facility Location Address Max use 1 Required N4 2700 Service Facility Location City, State, ZIP Code Max use 1 Required REF 2710 Service Facility Location Secondary Identification Max use 3 Optional Referring Provider Name Loop NM1 2500 Referring Provider Name Max use 1 Required REF 2710 Referring Provider Secondary Identification Max use 3 Optional Other Subscriber Information Loop 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 6/579 SBR 2900 Other Subscriber Information Max use 1 Required CAS 2950 Claim Level Adjustments Max use 5 Optional AMT 3000 Coordination of Benefits (COB) Payer Paid Amount Max use 1 Optional AMT 3000 Coordination of Benefits (COB) Total Non- Covered Amount Max use 1 Optional AMT 3000 Remaining Patient Liability Max use 1 Optional OI 3100 Other Insurance Coverage Information Max use 1 Required MIA 3150 Inpatient Adjudication Information Max use 1 Optional MOA 3200 Outpatient Adjudication Information Max use 1 Optional Other Subscriber Name Loop NM1 3250 Other Subscriber Name Max use 1 Required N3 3320 Other Subscriber Address Max use 1 Optional N4 3400 Other Subscriber City, State, ZIP Code Max use 1 Optional REF 3550 Other Subscriber Secondary Identification Max use 2 Optional Other Payer Name Loop NM1 3250 Other Payer Name Max use 1 Required N3 3320 Other Payer Address Max use 1 Optional N4 3400 Other Payer City, State, ZIP Code Max use 1 Optional DTP 3500 Claim Check or Remittance Date Max use 1 Optional REF 3550 Other Payer Claim Adjustment Indicator Max use 1 Optional REF 3550 Other Payer Claim Control Number Max use 1 Optional REF 3550 Other Payer Prior Authorization Number Max use 1 Optional REF 3550 Other Payer Referral Number Max use 1 Optional REF 3550 Other Payer Secondary Identifier Max use 2 Optional Other Payer Attending Provider Loop NM1 3250 Other Payer Attending Provider Max use 1 Required REF 3550 Other Payer Attending Provider Secondary Identification Max use 4 Required Other Payer Operating Physician Loop 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 7/579 NM1 3250 Other Payer Operating Physician Max use 1 Required REF 3550 Other Payer Operating Physician Secondary Identification Max use 4 Required Other Payer Other Operating Physician Loop NM1 3250 Other Payer Other Operating Physician Max use 1 Required REF 3550 Other Payer Other Operating Physician Secondary Identification Max use 4 Required Other Payer Service Facility Location Loop NM1 3250 Other Payer Service Facility Location Max use 1 Required REF 3550 Other Payer Service Facility Location Secondary Identification Max use 3 Required Other Payer Rendering Provider Name Loop NM1 3250 Other Payer Rendering Provider Name Max use 1 Required REF 3550 Other Payer Rendering Provider Secondary Identification Max use 4 Required Other Payer Referring Provider Loop NM1 3250 Other Payer Referring Provider Max use 1 Required REF 3550 Other Payer Referring Provider Secondary Identification Max use 3 Required Other Payer Billing Provider Loop NM1 3250 Other Payer Billing Provider Max use 1 Required REF 3550 Other Payer Billing Provider Secondary Identification Max use 2 Required Service Line Number Loop LX 3650 Service Line Number Max use 1 Required SV2 3750 Institutional Service Line Max use 1 Required PWK 4200 Line Supplemental Information Max use 10 Optional DTP 4550 Date - Service Date Max use 1 Optional REF 4700 Adjusted Repriced Line Item Reference Number Max use 1 Optional REF 4700 Line Item Control Number Max use 1 Optional REF 4700 Repriced Line Item Reference Number Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 8/579 AMT 4750 Facility Tax Amount Max use 1 Optional AMT 4750 Service Tax Amount Max use 1 Optional NTE 4850 Third Party Organization Notes Max use 1 Optional HCP 4920 Line Pricing/Repricing Information Max use 1 Optional Drug Identification Loop LIN 4930 Drug Identification Max use 1 Required CTP 4940 Drug Quantity Max use 1 Required REF 4950 Prescription or Compound Drug Association Number Max use 1 Optional Operating Physician Name Loop NM1 5000 Operating Physician Name Max use 1 Required REF 5250 Operating Physician Secondary Identification Max use 20 Optional Other Operating Physician Name Loop NM1 5000 Other Operating Physician Name Max use 1 Required REF 5250 Other Operating Physician Secondary Identification Max use 20 Optional Rendering Provider Name Loop NM1 5000 Rendering Provider Name Max use 1 Required REF 5250 Rendering Provider Secondary Identification Max use 20 Optional Referring Provider Name Loop NM1 5000 Referring Provider Name Max use 1 Required REF 5250 Referring Provider Secondary Identification Max use 20 Optional Line	Health Partner Plans 837 Health Care Claim_ Institutional.pdf
3550 Other Payer Claim Control Number Max use 1 Optional REF 3550 Other Payer Prior Authorization Number Max use 1 Optional REF 3550 Other Payer Referral Number Max use 1 Optional REF 3550 Other Payer Secondary Identifier Max use 2 Optional Other Payer Attending Provider Loop NM1 3250 Other Payer Attending Provider Max use 1 Required REF 3550 Other Payer Attending Provider Secondary Identification Max use 4 Required Other Payer Operating Physician Loop 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 7/579 NM1 3250 Other Payer Operating Physician Max use 1 Required REF 3550 Other Payer Operating Physician Secondary Identification Max use 4 Required Other Payer Other Operating Physician Loop NM1 3250 Other Payer Other Operating Physician Max use 1 Required REF 3550 Other Payer Other Operating Physician Secondary Identification Max use 4 Required Other Payer Service Facility Location Loop NM1 3250 Other Payer Service Facility Location Max use 1 Required REF 3550 Other Payer Service Facility Location Secondary Identification Max use 3 Required Other Payer Rendering Provider Name Loop NM1 3250 Other Payer Rendering Provider Name Max use 1 Required REF 3550 Other Payer Rendering Provider Secondary Identification Max use 4 Required Other Payer Referring Provider Loop NM1 3250 Other Payer Referring Provider Max use 1 Required REF 3550 Other Payer Referring Provider Secondary Identification Max use 3 Required Other Payer Billing Provider Loop NM1 3250 Other Payer Billing Provider Max use 1 Required REF 3550 Other Payer Billing Provider Secondary Identification Max use 2 Required Service Line Number Loop LX 3650 Service Line Number Max use 1 Required SV2 3750 Institutional Service Line Max use 1 Required PWK 4200 Line Supplemental Information Max use 10 Optional DTP 4550 Date - Service Date Max use 1 Optional REF 4700 Adjusted Repriced Line Item Reference Number Max use 1 Optional REF 4700 Line Item Control Number Max use 1 Optional REF 4700 Repriced Line Item Reference Number Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 8/579 AMT 4750 Facility Tax Amount Max use 1 Optional AMT 4750 Service Tax Amount Max use 1 Optional NTE 4850 Third Party Organization Notes Max use 1 Optional HCP 4920 Line Pricing/Repricing Information Max use 1 Optional Drug Identification Loop LIN 4930 Drug Identification Max use 1 Required CTP 4940 Drug Quantity Max use 1 Required REF 4950 Prescription or Compound Drug Association Number Max use 1 Optional Operating Physician Name Loop NM1 5000 Operating Physician Name Max use 1 Required REF 5250 Operating Physician Secondary Identification Max use 20 Optional Other Operating Physician Name Loop NM1 5000 Other Operating Physician Name Max use 1 Required REF 5250 Other Operating Physician Secondary Identification Max use 20 Optional Rendering Provider Name Loop NM1 5000 Rendering Provider Name Max use 1 Required REF 5250 Rendering Provider Secondary Identification Max use 20 Optional Referring Provider Name Loop NM1 5000 Referring Provider Name Max use 1 Required REF 5250 Referring Provider Secondary Identification Max use 20 Optional Line Adjudication Information Loop SVD 5400 Line Adjudication Information Max use 1 Required CAS 5450 Line Adjustment Max use 5 Optional DTP 5500 Line Check or Remittance Date Max use 1 Required AMT 5505 Remaining Patient Liability Max use 1 Optional Patient Hierarchical Level Loop HL 0010 Hierarchical Level Max use 1 Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 9/579 PAT 0070 Patient Information Max use 1 Required Patient Name Loop NM1 0150 Patient Name Max use 1 Required N3 0250 Patient Address Max use 1 Required N4 0300 Patient City, State, ZIP Code Max use 1 Required DMG 0320 Patient Demographic Information Max use 1 Required REF 0350 Property and Casualty Claim Number Max use 1 Optional REF 0350 Property and Casualty Patient Identifier Max use 1 Optional Claim Information Loop CLM 1300 Claim Information Max use 1 Required DTP 1350 Admission Date/Hour Max use 1 Optional DTP 1350 Date - Repricer Received Date Max use 1 Optional DTP 1350 Discharge Hour Max use 1 Optional DTP 1350 Statement Dates Max use 1 Required CL1 1400 Institutional Claim Code Max use 1 Required PWK 1550 Claim Supplemental Information Max use 10 Optional CN1 1600 Contract Information Max use 1 Optional AMT 1750 Patient Estimated Amount Due Max use 1 Optional REF 1800 Adjusted Repriced Claim Number Max use 1 Optional REF 1800 Auto Accident State Max use 1 Optional REF 1800 Claim Identifier For Transmission Intermediaries Max use 1 Optional REF 1800 Demonstration Project Identifier Max use 1 Optional REF 1800 Investigational Device Exemption Number Max use 5 Optional REF 1800 Medical Record Number Max use 1 Optional REF 1800 Payer Claim Control Number Max use 1 Optional REF 1800 Peer Review Organization (PRO) Approval Number Max use 1 Optional REF 1800 Prior Authorization Max use 1 Optional REF 1800 Referral Number Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 10/579 REF 1800 Repriced Claim Number Max use 1 Optional REF 1800 Service Authorization Exception Code Max use 1 Optional K3 1850 File Information Max use 10 Optional NTE 1900 Billing Note Max use 1 Optional NTE 1900 Claim Note Max use 10 Optional CRC 2200 EPSDT Referral Max use 1 Optional HI 2310 Admitting Diagnosis Max use 1 Optional HI 2310 Condition Information Max use 2 Optional HI 2310 Diagnosis Related Group (DRG) Information Max use 1 Optional HI 2310 External Cause of Injury Max use 1 Optional HI 2310 Occurrence Information Max use 2 Optional HI 2310 Occurrence Span Information Max use 2 Optional HI 2310 Other Diagnosis Information Max use 2 Optional HI 2310 Other Procedure Information Max use 2 Optional HI 2310 Patient's Reason For Visit Max use 1 Optional HI 2310 Principal Diagnosis Max use 1 Required HI 2310 Principal Procedure Information Max use 1 Optional HI 2310 Treatment Code Information Max use 2 Optional HI 2310 Value Information Max use 2 Optional HCP 2410 Claim Pricing/Repricing Information Max use 1 Optional Attending Provider Name Loop NM1 2500 Attending Provider Name Max use 1 Required PRV 2550 Attending Provider Specialty Information Max use 1 Optional REF 2710 Attending Provider Secondary Identification Max use 4 Optional Operating Physician Name Loop NM1 2500 Operating Physician Name Max use 1 Required REF 2710 Operating Physician Secondary Identification Max use 4 Optional Other Operating Physician Name Loop NM1 2500 Other Operating Physician Name Max use 1 Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 11/579 REF 2710 Other Operating Physician Secondary Identification Max use 4 Optional Rendering Provider Name Loop NM1 2500 Rendering Provider Name Max use 1 Required REF 2710 Rendering Provider Secondary Identification Max use 4 Optional Service Facility Location Name Loop NM1 2500 Service Facility Location Name Max use 1 Required N3 2650 Service Facility Location Address Max use 1 Required N4 2700 Service Facility Location City, State, ZIP Code Max use 1 Required REF 2710 Service Facility Location Secondary Identification Max use 3 Optional Referring Provider Name Loop NM1 2500 Referring Provider Name Max use 1 Required REF 2710 Referring Provider Secondary Identification Max use 3 Optional Other Subscriber Information Loop SBR 2900 Other Subscriber Information Max use 1 Required CAS 2950 Claim Level Adjustments Max use 5 Optional AMT 3000 Coordination of Benefits (COB) Payer Paid Amount Max use 1 Optional AMT 3000 Coordination of Benefits (COB) Total Non- Covered Amount Max use 1 Optional AMT 3000 Remaining Patient Liability Max use 1 Optional OI 3100 Other Insurance Coverage Information Max use 1 Required MIA 3150 Inpatient Adjudication Information Max use 1 Optional MOA 3200 Outpatient Adjudication Information Max use 1 Optional Other Subscriber Name Loop NM1 3250 Other Subscriber Name Max use 1 Required N3 3320 Other Subscriber Address Max use 1 Optional N4 3400 Other Subscriber City, State, ZIP Code Max use 1 Optional REF 3550 Other Subscriber Secondary Identification Max use 2 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 12/579 Other Payer Name Loop NM1 3250 Other Payer Name Max use 1 Required N3 3320 Other Payer Address Max use 1 Optional N4 3400 Other Payer City, State, ZIP Code Max use 1 Optional DTP 3500 Claim Check or Remittance Date Max use 1 Optional REF 3550 Other Payer Claim Adjustment Indicator Max use 1 Optional REF 3550 Other Payer Claim Control Number Max use 1 Optional REF 3550 Other Payer Prior Authorization Number Max use 1 Optional REF 3550 Other Payer Referral Number Max use 1 Optional REF 3550 Other Payer Secondary Identifier Max use 2 Optional Other Payer Attending Provider Loop NM1 3250 Other Payer Attending Provider Max use 1 Required REF 3550 Other Payer Attending Provider Secondary Identification Max use 4 Required Other Payer Operating Physician Loop NM1 3250 Other Payer Operating Physician Max use 1 Required REF 3550 Other Payer Operating Physician Secondary Identification Max use 4 Required Other Payer Other Operating Physician Loop NM1 3250 Other Payer Other Operating Physician Max use 1 Required REF 3550 Other Payer Other Operating Physician Secondary Identification Max use 4 Required Other Payer Service Facility Location Loop NM1 3250 Other Payer Service Facility Location Max use 1 Required REF 3550 Other Payer Service Facility Location Secondary Identification Max use 3 Required Other Payer Rendering Provider Name Loop NM1 3250 Other Payer Rendering Provider Name Max use 1 Required REF 3550 Other Payer Rendering Provider Secondary Identification Max use 4 Required Other Payer Referring Provider Loop 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 13/579 NM1 3250 Other Payer Referring Provider Max use 1 Required REF 3550 Other Payer Referring Provider Secondary Identification Max use 3 Required Other Payer Billing Provider Loop NM1 3250 Other Payer Billing Provider Max use 1 Required REF 3550 Other Payer Billing Provider Secondary Identification Max use 2 Required Service Line Number Loop LX 3650 Service Line Number Max use 1 Required SV2 3750 Institutional Service Line Max use 1 Required PWK 4200 Line Supplemental Information Max use 10 Optional DTP 4550 Date - Service Date Max use 1 Optional REF 4700 Adjusted Repriced Line Item Reference Number Max use 1 Optional REF 4700 Line Item Control Number Max use 1 Optional REF 4700 Repriced Line Item Reference Number Max use 1 Optional AMT 4750 Facility Tax Amount Max use 1 Optional AMT 4750 Service Tax Amount Max use 1 Optional NTE 4850 Third Party Organization Notes Max use 1 Optional HCP 4920 Line Pricing/Repricing Information Max use 1 Optional Drug Identification Loop LIN 4930 Drug Identification Max use 1 Required CTP 4940 Drug Quantity Max use 1 Required REF 4950 Prescription or Compound Drug Association Number Max use 1 Optional Operating Physician Name Loop NM1 5000 Operating Physician Name Max use 1 Required REF 5250 Operating Physician Secondary Identification Max use 20 Optional Other Operating Physician Name Loop NM1 5000 Other Operating Physician Name Max use 1 Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 14/579 REF 5250 Other Operating Physician Secondary Identification Max use 20 Optional Rendering Provider Name Loop NM1 5000 Rendering Provider Name Max use 1 Required REF 5250 Rendering Provider Secondary Identification Max use 20 Optional Referring Provider Name Loop NM1 5000 Referring Provider Name Max use 1 Required REF 5250 Referring Provider Secondary Identification Max use 20 Optional Line Adjudication Information Loop SVD 5400 Line Adjudication Information Max use 1 Required CAS 5450 Line Adjustment Max use 5 Optional DTP 5500 Line Check or Remittance Date Max use 1 Required AMT 5505 Remaining Patient Liability Max use 1 Optional SE 5550 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 15/579 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 XXXXXXXXXXXXXXXXXX2501312345^0050100000000 0XX>~ Max	Health Partner Plans 837 Health Care Claim_ Institutional.pdf
3550 Other Payer Other Operating Physician Secondary Identification Max use 4 Required Other Payer Service Facility Location Loop NM1 3250 Other Payer Service Facility Location Max use 1 Required REF 3550 Other Payer Service Facility Location Secondary Identification Max use 3 Required Other Payer Rendering Provider Name Loop NM1 3250 Other Payer Rendering Provider Name Max use 1 Required REF 3550 Other Payer Rendering Provider Secondary Identification Max use 4 Required Other Payer Referring Provider Loop 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 13/579 NM1 3250 Other Payer Referring Provider Max use 1 Required REF 3550 Other Payer Referring Provider Secondary Identification Max use 3 Required Other Payer Billing Provider Loop NM1 3250 Other Payer Billing Provider Max use 1 Required REF 3550 Other Payer Billing Provider Secondary Identification Max use 2 Required Service Line Number Loop LX 3650 Service Line Number Max use 1 Required SV2 3750 Institutional Service Line Max use 1 Required PWK 4200 Line Supplemental Information Max use 10 Optional DTP 4550 Date - Service Date Max use 1 Optional REF 4700 Adjusted Repriced Line Item Reference Number Max use 1 Optional REF 4700 Line Item Control Number Max use 1 Optional REF 4700 Repriced Line Item Reference Number Max use 1 Optional AMT 4750 Facility Tax Amount Max use 1 Optional AMT 4750 Service Tax Amount Max use 1 Optional NTE 4850 Third Party Organization Notes Max use 1 Optional HCP 4920 Line Pricing/Repricing Information Max use 1 Optional Drug Identification Loop LIN 4930 Drug Identification Max use 1 Required CTP 4940 Drug Quantity Max use 1 Required REF 4950 Prescription or Compound Drug Association Number Max use 1 Optional Operating Physician Name Loop NM1 5000 Operating Physician Name Max use 1 Required REF 5250 Operating Physician Secondary Identification Max use 20 Optional Other Operating Physician Name Loop NM1 5000 Other Operating Physician Name Max use 1 Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 14/579 REF 5250 Other Operating Physician Secondary Identification Max use 20 Optional Rendering Provider Name Loop NM1 5000 Rendering Provider Name Max use 1 Required REF 5250 Rendering Provider Secondary Identification Max use 20 Optional Referring Provider Name Loop NM1 5000 Referring Provider Name Max use 1 Required REF 5250 Referring Provider Secondary Identification Max use 20 Optional Line Adjudication Information Loop SVD 5400 Line Adjudication Information Max use 1 Required CAS 5450 Line Adjustment Max use 5 Optional DTP 5500 Line Check or Remittance Date Max use 1 Required AMT 5505 Remaining Patient Liability Max use 1 Optional SE 5550 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 15/579 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 XXXXXXXXXXXXXXXXXX2501312345^0050100000000 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 16/579 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 17/579 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 18/579 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GSHCXXXXXXXXXXX20250131003800000000X00501 0X223A3~ Max use 1 Required GS-01 479 Functional Identifier Code Identifier (ID) Required Code identifying a group of application related transaction sets HC Health Care Claim (837) 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 19/579 T Transportation Data Coordinating Committee (TDCC) 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 005010X223A3 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 20/579 Heading ST 0050 Heading > ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST8370001005010X223A3~ 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). 837 Health Care Claim 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 Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges. ST-03 1705 Version, Release, or Industry Identifier String (AN) Required Reference assigned to identify Implementation Convention The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08. Usage notes This element must be populated with the guide identifier named in Section 1.2. This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is used at translation time. 005010X223A3 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 21/579 BHT 0100 Heading > BHT Beginning of Hierarchical Transaction To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time Usage notes The second example denotes the case where the entire transaction set contains ENCOUNTERS. Example BHT001900XXXX202501310823*RP~ Max use 1 Required BHT-01 1005 Hierarchical Structure Code Identifier (ID) Required Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set 0019 Information Source, Subscriber, Dependent BHT-02 353 Transaction Set Purpose Code Identifier (ID) Required Code identifying purpose of transaction set Usage notes BHT02 is intended to convey the electronic transmission status of the 837 batch contained in this ST-SE envelope. The terms "original" and "reissue" refer to the electronic transmission status of the 837 batch, not the billing status. 00 Original Original transmissions are transmissions which have never been sent to the receiver. BHT-03 127 Originator Application Transaction Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system. Usage notes The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number. This field is limited to 30 characters. BHT-04 373 Transaction Set Creation Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi	Health Partner Plans 837 Health Care Claim_ Institutional.pdf
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). 837 Health Care Claim 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 Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges. ST-03 1705 Version, Release, or Industry Identifier String (AN) Required Reference assigned to identify Implementation Convention The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08. Usage notes This element must be populated with the guide identifier named in Section 1.2. This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is used at translation time. 005010X223A3 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 21/579 BHT 0100 Heading > BHT Beginning of Hierarchical Transaction To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time Usage notes The second example denotes the case where the entire transaction set contains ENCOUNTERS. Example BHT001900XXXX202501310823RP~ Max use 1 Required BHT-01 1005 Hierarchical Structure Code Identifier (ID) Required Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set 0019 Information Source, Subscriber, Dependent BHT-02 353 Transaction Set Purpose Code Identifier (ID) Required Code identifying purpose of transaction set Usage notes BHT02 is intended to convey the electronic transmission status of the 837 batch contained in this ST-SE envelope. The terms "original" and "reissue" refer to the electronic transmission status of the 837 batch, not the billing status. 00 Original Original transmissions are transmissions which have never been sent to the receiver. BHT-03 127 Originator Application Transaction Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system. Usage notes The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number. This field is limited to 30 characters. BHT-04 373 Transaction Set Creation Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 22/579 year BHT04 is the date the transaction was created within the business application system. Usage notes This is the date that the original submitter created the claim file from their business application system. BHT-05 337 Transaction Set Creation Time Time (TM) Required HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99) BHT05 is the time the transaction was created within the business application system. Usage notes This is the time that the original submitter created the claim file from their business application system. BHT-06 640 Claim Identifier Identifier (ID) Required Code specifying the type of transaction 31 Subrogation Demand The subrogation demand code is only for use by state Medicaid agencies performing post payment recovery claiming with willing trading partners. NOTE: At the time of this writing, Subrogation Demand is not a HIPAA mandated use of the 837 transaction. CH Chargeable Use CH when the transaction contains only fee for service claims or claims with at least one chargeable line item. If it is not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters, use CH. RP Reporting Use RP when the entire ST-SE envelope contains only capitated encounters. Use RP when the transaction is being sent to an entity (usually not a payer or a normal provider payer transmission intermediary) for purposes other than adjudication of a claim. Such an entity could be a state health data agency which is using the 837 for health data reporting purposes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 23/579 1000A Submitter Name Loop Max 1 Required Variants (all may be used) Receiver Name Loop NM1 0200 Heading > Submitter Name Loop > NM1 Submitter Name To supply the full name of an individual or organizational entity Usage notes The submitter is the entity responsible for the creation and formatting of this transaction. Example NM1412EMDEONXXXXXXX*46133052274~ 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 41 Submitter 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 Submitter Last or Organization Name String (AN) Required Individual last name or organizational name EMDEON NM1-04 1036 Submitter First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Submitter Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-08 66 Identification Code Qualifier Identifier (ID) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 24/579 Code designating the system/method of code structure used for Identification Code (67) 46 Electronic Transmitter Identification Number (ETIN) Established by trading partner agreement NM1-09 67 Submitter Identifier String (AN) Required Code identifying a party or other code 133052274 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 25/579 PER 0450 Heading > Submitter Name Loop > PER Submitter EDI 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 must always include 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. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". The contact information in this segment identifies the person in the submitter organization who deals with data transmission issues. If data transmission problems arise, this is the person to contact in the submitter organization. There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions. Example PERICEMDEON CUSTOMER SOLUTIONSTE8008456592E MXXXXXEMXXXX~ If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required Max use 2 Required 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-02 93 Submitter Contact Name String (AN) Optional Free-form name EMDEON CUSTOMER SOLUTIONS PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number TE Telephone PER-04 364 Communication Number String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 26/579 1000A Submitter Name Loop end Complete communications number including country or area code when applicable 8008456592 PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-06 364 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 FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 27/579 1000B Receiver Name Loop Max 1 Required Variants (all may be used) Submitter Name Loop NM1 0200 Heading > Receiver Name Loop > NM1 Receiver Name To supply the full name of an individual or organizational entity Example NM1402XX***46801420001~ 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 40 Receiver 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 Receiver 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) 46 Electronic Transmitter Identification Number (ETIN) NM1-09 67 Receiver Primary Identifier String (AN) Required Code identifying a party or other code 801420001 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 28/579 1000B Receiver Name Loop end Heading end 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 29/579 Detail 2000A Billing Provider Hierarchical Level Loop Max >1 Required HL 0010 Detail > Billing Provider Hierarchical Level Loop > HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL1201~ Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 20 Information Source HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1 Additional Subordinate HL Data Segment in This Hierarchical Structure. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 30/579 PRV 0030 Detail > Billing Provider Hierarchical Level Loop > PRV Billing Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when the payer's adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send. Example PRVBIPXC*XX~ Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code	Health Partner Plans 837 Health Care Claim_ Institutional.pdf
> Receiver Name Loop > NM1 Receiver Name To supply the full name of an individual or organizational entity Example NM1402XX***46801420001~ 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 40 Receiver 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 Receiver 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) 46 Electronic Transmitter Identification Number (ETIN) NM1-09 67 Receiver Primary Identifier String (AN) Required Code identifying a party or other code 801420001 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 28/579 1000B Receiver Name Loop end Heading end 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 29/579 Detail 2000A Billing Provider Hierarchical Level Loop Max >1 Required HL 0010 Detail > Billing Provider Hierarchical Level Loop > HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL1201~ Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 20 Information Source HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1 Additional Subordinate HL Data Segment in This Hierarchical Structure. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 30/579 PRV 0030 Detail > Billing Provider Hierarchical Level Loop > PRV Billing Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when the payer's adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send. Example PRVBIPXCXX~ Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider BI Billing PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 31/579 CUR 0100 Detail > Billing Provider Hierarchical Level Loop > CUR Foreign Currency Information To specify the currency (dollars, pounds, francs, etc.) used in a transaction Usage notes Required when the amounts represented in this transaction are currencies other than the United States dollar. If not required by this implementation guide, do not send. It is REQUIRED that all amounts reported within the transaction are of the currency named in this segment. If this segment is not used, then it is required that all amounts in this transaction be expressed in US dollars. Example CUR85XXX~ 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 85 Billing Provider 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 The submitter must use the Currency Code, not the Country Code, for this element. For example the Currency Code CAD = Canadian dollars would be valid, while CA = Canada would be invalid. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 32/579 2010AA Billing Provider Name Loop Max 1 Required Variants (all may be used) Pay-to Address Name Loop Pay-To Plan Name Loop NM1 0150 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > NM1 Billing Provider Name To supply the full name of an individual or organizational entity Usage notes Beginning on the NPI compliance date: When the Billing Provider is an organization health care provider, the organization health care provider's NPI or its subpart's NPI is reported in NM109. When a health care provider organization has determined that it needs to enumerate its subparts, it will report the NPI of a subpart as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be the same identifier sent to any trading partner. For additional explanation, see section 1.10.3 Organization Health Care Provider Subpart Presentation. Prior to the NPI compliance date, proprietary identifiers necessary for the receiver to identify the Billing Provider entity are to be reported in the REF segment of Loop ID- 2010BB. The Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099 purposes must be reported in the REF segment of this loop. When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment. The TIN to be used for 1099 purposes must be reported in the REF (Tax Identification Number) segment of this loop. Example NM1852X****XXXXXX~ If either Identification Code Qualifier (NM1-08) or Billing Provider 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 85 Billing Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 33/579 2 Non-Person Entity NM1-03 1035 Billing Provider Organizational Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Billing Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes Use appropriate NPI number. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 34/579 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N3 Billing Provider Address To specify the location of the named party Usage notes The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-To Address Loop (Loop ID-2010AB), if necessary. Example N3XXXXXXX~ Max use 1 Required N3-01 166 Billing Provider Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Billing Provider Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 35/579 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > N4 Billing Provider City, State, ZIP Code To specify the geographic place of the named party Usage notes Include city, 2-character state code and 9-digit ZIP code. Example N4XXXXXXXXXXXXXXXXXX~ Only one of Billing Provider State or Province 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 Billing Provider 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 Billing Provider State or Province 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 Billing Provider 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 When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 36/579 Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 37/579 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF Billing Provider Tax Identification To specify identifying information Usage notes This is the tax identification number (TIN) of the entity to be paid for the submitted services. Example REFEIXX~ Max use 1 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. REF-02 127 Billing Provider Tax Identification 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 38/579 PER 0400 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > PER Billing Provider Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when this information is different than that contained in the Loop ID-1000A - Submitter PER segment. 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 must always include 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. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions. Example PERICXXXXTEXXEMXXXTEXXXXX~ If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (PER-08)	Health Partner Plans 837 Health Care Claim_ Institutional.pdf
3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 36/579 Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 37/579 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > REF Billing Provider Tax Identification To specify identifying information Usage notes This is the tax identification number (TIN) of the entity to be paid for the submitted services. Example REFEIXX~ Max use 1 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. REF-02 127 Billing Provider Tax Identification 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 38/579 PER 0400 Detail > Billing Provider Hierarchical Level Loop > Billing Provider Name Loop > PER Billing Provider Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when this information is different than that contained in the Loop ID-1000A - Submitter PER segment. 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 must always include 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. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions. Example PERICXXXXTEXXEMXXXTEXXXXX~ If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (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 IC Information Contact PER-02 93 Billing Provider 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 Communication Number Min 1 Max 256 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 39/579 2010AA Billing Provider Name Loop end 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 FX Facsimile TE Telephone PER-06 364 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 FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 40/579 2010AB Pay-to Address Name Loop Max 1 Optional Variants (all may be used) Billing Provider Name Loop Pay-To Plan Name Loop NM1 0150 Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > NM1 Pay-to Address Name To supply the full name of an individual or organizational entity Usage notes Required when the address for payment is different than that of the Billing Provider. If not required by this implementation guide, do not send.; The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address. There are no applicable identifiers for Pay-To Address information. Example NM1872~ 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 87 Pay-to Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 41/579 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > N3 Pay-to Address - ADDRESS To specify the location of the named party Example N3XXXXX~ Max use 1 Required N3-01 166 Pay-To Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Pay-To Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 42/579 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Pay-to Address Name Loop > N4 Pay-To Address City, State, ZIP Code To specify the geographic place of the named party Usage notes Include city, 2-character state code and 9-digit ZIP code. Example N4XXXXXXXXXXXXXXXXXX~ Only one of Pay-to Address 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 Pay-to Address 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 Pay-to Address 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 Pay-to Address 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 43/579 2010AB Pay-to Address Name Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 44/579 2010AC Pay-To Plan Name Loop Max 1 Optional Variants (all may be used) Billing Provider Name Loop Pay-to Address Name Loop NM1 0150 Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > NM1 Pay-To Plan Name To supply the full name of an individual or organizational entity Usage notes Required when willing trading partners agree to use this implementation for their subrogation payment requests. This loop may only be used when BHT06 = 31. Example NM1PE2XXXX***PIXXXXXX~ 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 PE Payee PE is used to indicate the subrogated payee. 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 Pay-To Plan Organizational 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) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 45/579 Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Pay-To Plan Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 46/579 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > N3 Pay-to Plan Address To specify the location of the named party Example N3XXXXXXXXXXX~ Max use 1 Required N3-01 166 Pay-To Plan Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Pay-To Plan Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 47/579 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > N4 Pay-To Plan City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXX~ Only one of Pay-To Plan State or Province 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 Pay-To Plan 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 Pay-To Plan State or Province 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 Pay-To Plan 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. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 48/579 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > REF Pay-to Plan Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REFFYXXXXX~ Variants (all may be used) REF Pay-To Plan Tax Identification Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is	Health Partner Plans 837 Health Care Claim_ Institutional.pdf
and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Pay-To Plan Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 46/579 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > N3 Pay-to Plan Address To specify the location of the named party Example N3XXXXXXXXXXX~ Max use 1 Required N3-01 166 Pay-To Plan Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Pay-To Plan Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 47/579 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > N4 Pay-To Plan City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXX~ Only one of Pay-To Plan State or Province 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 Pay-To Plan 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 Pay-To Plan State or Province 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 Pay-To Plan 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. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 48/579 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > REF Pay-to Plan Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REFFYXXXXX~ Variants (all may be used) REF Pay-To Plan Tax Identification Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Pay-to Plan 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 49/579 2010AC Pay-To Plan Name Loop end REF 0350 Detail > Billing Provider Hierarchical Level Loop > Pay-To Plan Name Loop > REF Pay-To Plan Tax Identification Number To specify identifying information Example REFEIXXXXX~ Variants (all may be used) REF Pay-to Plan Secondary Identification Max use 1 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. REF-02 127 Pay-To Plan Tax Identification 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 50/579 2000B Subscriber Hierarchical Level Loop Max >1 Required HL 0010 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL21221~ Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-02 734 Hierarchical Parent ID Number Min 1 Max 12 String (AN) Required Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 22 Subscriber HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 51/579 0 No Subordinate HL Segment in This Hierarchical Structure. 1 Additional Subordinate HL Data Segment in This Hierarchical Structure. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 52/579 SBR 0050 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > SBR Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Example SBRC18XXXXXXX****OF~ Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. A Payer Responsibility Four B Payer Responsibility Five C Payer Responsibility Six D Payer Responsibility Seven E Payer Responsibility Eight F Payer Responsibility Nine G Payer Responsibility Ten H Payer Responsibility Eleven P Primary S Secondary T Tertiary U Unknown This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer. SBR-02 1069 Individual Relationship Code Identifier (ID) Optional Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. 18 Self SBR-03 127 Subscriber Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 53/579 This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop ID-2010BA-NM109. SBR-04 93 Subscriber Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required Code identifying type of claim 11 Other Non-Federal Programs 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance 16 Health Maintenance Organization (HMO) Medicare Risk 17 Dental Maintenance Organization AM Automobile Medical BL Blue Cross/Blue Shield CH Champus CI Commercial Insurance Co. DS Disability FI Federal Employees Program HM Health Maintenance Organization LM Liability Medical MA Medicare Part A MB Medicare Part B MC Medicaid OF Other Federal Program Use code OF when submitting Medicare Part D claims. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 54/579 2010BA Subscriber Name Loop Max 1 Required Variants (all may be used) Payer Name Loop NM1 0150 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > NM1 Subscriber Name To supply the full name of an individual or organizational entity Usage notes In worker's compensation or other property and casualty claims, the "subscriber" may be a non-person entity (for example, the employer). However, this varies by state. Example NM1IL2XXXXXXXXXXXXXXXX*XXXXXXIIXXX~ If either Identification Code Qualifier (NM1-08) or Subscriber Primary 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 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) Required 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 55/579 Individual middle name or initial NM1-07 1039 Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes Examples: I, II, III, IV, Jr, Sr This data element is used only to indicate generation or patronymic. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) II Standard Unique Health Identifier for each Individual in the United States Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead. MI Member Identification Number The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.) MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Subscriber Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 56/579 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N3 Subscriber Address To specify the location of the named party Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example N3XXX*XXXX~ Max use 1 Optional N3-01 166 Subscriber Address Line Min 1 Max 55 String (AN) Required Address information N3-02	Health Partner Plans 837 Health Care Claim_ Institutional.pdf
Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > NM1 Subscriber Name To supply the full name of an individual or organizational entity Usage notes In worker's compensation or other property and casualty claims, the "subscriber" may be a non-person entity (for example, the employer). However, this varies by state. Example NM1IL2XXXXXXXXXXXXXXXXXXXXXXIIXXX~ If either Identification Code Qualifier (NM1-08) or Subscriber Primary 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 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) Required 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 55/579 Individual middle name or initial NM1-07 1039 Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes Examples: I, II, III, IV, Jr, Sr This data element is used only to indicate generation or patronymic. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) II Standard Unique Health Identifier for each Individual in the United States Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value `MI' instead. MI Member Identification Number The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.) MI is also intended to be used in claims submitted to the Indian Health Service/Contract Health Services (IHS/CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS/CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Subscriber Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 56/579 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N3 Subscriber Address To specify the location of the named party Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example N3XXXXXXX~ Max use 1 Optional N3-01 166 Subscriber Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Subscriber Address Line Min 1 Max 55 String (AN) Optional Address information 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 57/579 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > N4 Subscriber City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example N4XXXXXXXXXXXX~ Only one of Subscriber 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 Subscriber 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 Subscriber 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 Subscriber 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 58/579 Use the country subdivision codes from Part 2 of ISO 3166. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 59/579 DMG 0320 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > DMG Subscriber Demographic Information To supply demographic information Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example DMGD8XXXM~ Max use 1 Optional DMG-01 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD DMG-02 1251 Subscriber Birth Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times DMG02 is the date of birth. DMG-03 1068 Subscriber Gender Code Identifier (ID) Required Code indicating the sex of the individual F Female M Male U Unknown 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 60/579 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF Property and Casualty Claim Number To specify identifying information Usage notes This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.; This segment is not a HIPAA requirement as of this writing. Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send. Example REFY4XXXX~ Variants (all may be used) REF Subscriber Secondary Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Y4 Agency Claim Number REF-02 127 Property Casualty Claim 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 61/579 2010BA Subscriber Name Loop end REF 0350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Subscriber Name Loop > REF Subscriber Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. Example REFSYXXXXXX~ Variants (all may be used) REF Property and Casualty Claim Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Subscriber Supplemental 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 62/579 2010BB Payer Name Loop Max 1 Required Variants (all may be used) Subscriber Name Loop NM1 0150 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > NM1 Payer Name To supply the full name of an individual or organizational entity Usage notes This is the destination payer. For the purposes of this implementation the term payer is synonymous with several other terms, such as, repricer and third party administrator. Example NM1PR2XXX***XVXXXXX~ 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 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 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) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 63/579 Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Payer Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 64/579 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N3 Payer Address To specify the location of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N3XXXXXXXXXXXX~ Max use 1 Optional 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 65/579 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N4 Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N4XXXXXXXXXXX~ 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 Optional 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	Health Partner Plans 837 Health Care Claim_ Institutional.pdf
when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 63/579 Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Payer Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 64/579 N3 0250 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N3 Payer Address To specify the location of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N3XXXXXXXXXXXX~ Max use 1 Optional 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 65/579 N4 0300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > N4 Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N4XXXXXXXXXXX~ 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 Optional 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. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 66/579 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 67/579 REF 0350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > REF Billing Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated NPI Implementation Date when an additional identification number is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in Loop 2010AA is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REFLUXXXX~ Variants (all may be used) REF Payer Secondary Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Billing 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 68/579 2010BB Payer Name Loop end REF 0350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Payer Name Loop > REF Payer Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REFNFXXXXX~ Variants (all may be used) REF Billing Provider Secondary Identification Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Payer Additional 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 69/579 2300 Claim Information Loop Max 100 Optional CLM 1300 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CLM Claim Information To specify basic data about the claim Usage notes The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA- IEA. Willing trading partners can agree to set limits higher. For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this, the claim information is said to "float." Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber/Patient HL Segment explanation in section 1.4.3.2.2.1 for details. Example CLMXXXXX00000000000000*X>A>XBNI********** *8~ Max use 1 Required CLM-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 The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim. When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN/DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies. The maximum number of characters to be supported for this field is `20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 70/579 CLM-02 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLM02 is the total amount of all submitted charges of service segments for this claim. Usage notes The Total Claim Charge Amount must be greater than or equal to zero. The total claim charge amount must balance to the sum of all service line charge amounts reported in the Institutional Service Line (SV2) segments for this claim. CLM-05 C023 Health Care Service Location Information To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered Max use 1 Required C023-01 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. C023-02 1332 Facility Code Qualifier Identifier (ID) Required Code identifying the type of facility referenced C023-02 qualifies C023-01 and C023-03. A Uniform Billing Claim Form Bill Type C023-03 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Required Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type CLM-07 1359 Assignment or Plan Participation Code Identifier (ID) Required Code indicating whether the provider accepts assignment Usage notes Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08. A Assigned Required when the provider accepts assignment and/or has a participation agreement with the destination payer. OR Required when the provider does not accept assignment and/or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 71/579 B Assignment Accepted on Clinical Lab Services Only Required when the provider accepts assignment for Clinical Lab Services only. C Not Assigned Required when neither codes A' nor B' apply. CLM-08 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code `W' when the patient refuses to assign benefits. Y Yes CLM-09 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature	Health Partner Plans 837 Health Care Claim_ Institutional.pdf
Service Location Information To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered Max use 1 Required C023-01 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. C023-02 1332 Facility Code Qualifier Identifier (ID) Required Code identifying the type of facility referenced C023-02 qualifies C023-01 and C023-03. A Uniform Billing Claim Form Bill Type C023-03 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Required Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type CLM-07 1359 Assignment or Plan Participation Code Identifier (ID) Required Code indicating whether the provider accepts assignment Usage notes Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08. A Assigned Required when the provider accepts assignment and/or has a participation agreement with the destination payer. OR Required when the provider does not accept assignment and/or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 71/579 B Assignment Accepted on Clinical Lab Services Only Required when the provider accepts assignment for Clinical Lab Services only. C Not Assigned Required when neither codes A' nor B' apply. CLM-08 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM08 is assignment of benefits indicator. A "Y" value indicates insured or authorized person authorizes benefits to be assigned to the provider; an "N" value indicates benefits have not been assigned to the provider. Usage notes This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code `W' when the patient refuses to assign benefits. Y Yes CLM-09 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. CLM-20 1514 Delay Reason Code Identifier (ID) Optional Code indicating the reason why a request was delayed 1 Proof of Eligibility Unknown or Unavailable 2 Litigation 3 Authorization Delays 4 Delay in Certifying Provider 5 Delay in Supplying Billing Forms 6 Delay in Delivery of Custom-made Appliances 7 Third Party Processing Delay 8 Delay in Eligibility Determination 9 Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 72/579 10 Administration Delay in the Prior Approval Process 11 Other 15 Natural Disaster 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 73/579 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Admission Date/Hour To specify any or all of a date, a time, or a time period Usage notes Required on inpatient claims. If not required by this implementation guide, do not send. Example DTP435DTX~ Variants (all may be used) DTP Date - Repricer Received Date DTP Discharge Hour DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 435 Admission DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. Usage notes Selection of the appropriate qualifier is designated by the NUBC Billing Manual. D8 Date Expressed in Format CCYYMMDD DT Date and Time Expressed in Format CCYYMMDDHHMM DTP-03 1251 Admission Date and Hour Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 74/579 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Date - Repricer Received Date To specify any or all of a date, a time, or a time period Usage notes Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send. Example DTP050D8XXX~ Variants (all may be used) DTP Admission Date/Hour DTP Discharge Hour DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Repricer Received Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 75/579 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Discharge Hour To specify any or all of a date, a time, or a time period Usage notes Required on all final inpatient claims. If not required by this implementation guide, do not send. Example DTP096TMXXXXXX~ Variants (all may be used) DTP Admission Date/Hour DTP Date - Repricer Received Date DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 096 Discharge DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. TM Time Expressed in Format HHMM DTP-03 1251 Discharge Time Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 76/579 DTP 1350 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > DTP Statement Dates To specify any or all of a date, a time, or a time period Example DTP434RD8X~ Variants (all may be used) DTP Admission Date/Hour DTP Date - Repricer Received Date DTP Discharge Hour Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 434 Statement DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD Use RD8 to indicate the from and through date of the statement. When the statement is for a single date of service, the from and through date are the same. DTP-03 1251 Statement From and To Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 77/579 CL1 1400 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CL1 Institutional Claim Code To supply information specific to hospital claims Example CL1XXXX~ Max use 1 Required CL1-01 1315 Admission Type Code Min 1 Max 1 Identifier (ID) Required Code indicating the priority of this admission CL1-02 1314 Admission Source Code Min 1 Max 1 Identifier (ID) Optional Code indicating the source of this admission CL1-03 1352 Patient Status Code Min 1 Max 2 Identifier (ID) Required Code indicating patient status as of the "statement covers through date" 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 78/579 PWK 1550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > PWK Claim Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWKA4FT*ACXXXXXX~ If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 04 Drugs Administered 05 Treatment Diagnosis 06 Initial Assessment 07 Functional Goals 08 Plan of Treatment 09 Progress Report 10 Continued Treatment 11 Chemical Analysis 13 Certified Test Report 15 Justification for Admission 21 Recovery Plan A3 Allergies/Sensitivities Document A4 Autopsy Report AM Ambulance Certification AS Admission Summary B2 Prescription B3 Physician Order B4 Referral Form BR Benchmark Testing Results BS Baseline BT Blanket Test Results CB Chiropractic Justification 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 79/579 CK Consent Form(s) CT Certification D2 Drug Profile Document DA Dental Models DB Durable Medical Equipment Prescription DG Diagnostic Report DJ Discharge Monitoring Report DS Discharge Summary EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record IR State School Immunization Records LA Laboratory Results M1 Medical Record Attachment MT Models NN Nursing Notes OB Operative Note OC Oxygen Content Averaging Report OD Orders and Treatments Document OE Objective Physical Examination (including vital signs) Document OX Oxygen Therapy Certification OZ Support Data for Claim P4 Pathology Report P5 Patient Medical History Document PE Parenteral or Enteral Certification PN Physical Therapy Notes PO Prosthetics or Orthotic Certification PQ Paramedical Results PY Physician's Report PZ Physical Therapy Certification RB Radiology Films RR Radiology Reports RT Report of Tests and Analysis Report RX Renewable Oxygen Content Averaging Report SG Symptoms Document V5 Death Notification XP Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent AA Available on Request at Provider Site This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at	Health Partner Plans 837 Health Care Claim_ Institutional.pdf
PWK 1550 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > PWK Claim Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWKA4FT**ACXXXXXX~ If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 04 Drugs Administered 05 Treatment Diagnosis 06 Initial Assessment 07 Functional Goals 08 Plan of Treatment 09 Progress Report 10 Continued Treatment 11 Chemical Analysis 13 Certified Test Report 15 Justification for Admission 21 Recovery Plan A3 Allergies/Sensitivities Document A4 Autopsy Report AM Ambulance Certification AS Admission Summary B2 Prescription B3 Physician Order B4 Referral Form BR Benchmark Testing Results BS Baseline BT Blanket Test Results CB Chiropractic Justification 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 79/579 CK Consent Form(s) CT Certification D2 Drug Profile Document DA Dental Models DB Durable Medical Equipment Prescription DG Diagnostic Report DJ Discharge Monitoring Report DS Discharge Summary EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record IR State School Immunization Records LA Laboratory Results M1 Medical Record Attachment MT Models NN Nursing Notes OB Operative Note OC Oxygen Content Averaging Report OD Orders and Treatments Document OE Objective Physical Examination (including vital signs) Document OX Oxygen Therapy Certification OZ Support Data for Claim P4 Pathology Report P5 Patient Medical History Document PE Parenteral or Enteral Certification PN Physical Therapy Notes PO Prosthetics or Orthotic Certification PQ Paramedical Results PY Physician's Report PZ Physical Therapy Certification RB Radiology Films RR Radiology Reports RT Report of Tests and Analysis Report RX Renewable Oxygen Content Averaging Report SG Symptoms Document V5 Death Notification XP Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent AA Available on Request at Provider Site This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 80/579 Required when the actual attachment is maintained by an attachment warehouse or similar vendor. FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 81/579 CN1 1600 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CN1 Contract Information To specify basic data about the contract or contract line item Usage notes Required when the submitter is contractually obligated to supply this information on post-adjudicated claims. If not required by this implementation guide, do not send. The developers of this implementation guide note that the CN1 segment is for use only for post-adjudicated claims, which do not meet the definition of a health care claim under HIPAA. Consequently, at the time of this writing, the CN1 segment is for non- HIPAA use only. Example CN10300000000000XXXXXX00000X~ Max use 1 Optional CN1-01 1166 Contract Type Code Identifier (ID) Required Code identifying a contract type 01 Diagnosis Related Group (DRG) 02 Per Diem 03 Variable Per Diem 04 Flat 05 Capitated 06 Percent 09 Other CN1-02 782 Contract Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CN102 is the contract amount. CN1-03 332 Contract Percentage Min 1 Max 6 Decimal number (R) Optional Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through 100%) CN103 is the allowance or charge percent. CN1-04 127 Contract 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 CN104 is the contract code. CN1-05 338 Terms Discount Percentage Min 1 Max 6 Decimal number (R) Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 82/579 Terms discount percentage, expressed as a percent, available to the purchaser if an invoice is paid on or before the Terms Discount Due Date CN1-06 799 Contract Version Identifier Min 1 Max 30 String (AN) Optional Revision level of a particular format, program, technique or algorithm CN106 is an additional identifying number for the contract. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 83/579 AMT 1750 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > AMT Patient Estimated Amount Due To indicate the total monetary amount Usage notes Required when the Patient Responsibility Amount is applicable to this claim. If not required by this implementation guide, do not send. Example AMTF3000000000000000~ Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount F3 Patient Responsibility - Estimated AMT-02 782 Patient Responsibility Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 84/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Adjusted Repriced Claim Number To specify identifying information Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF9CX~ Variants (all may be used) REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9C Adjusted Repriced Claim Reference Number REF-02 127 Adjusted Repriced Claim Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 85/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Auto Accident State To specify identifying information Usage notes Required when the services reported on this claim are related to an auto accident and the accident occurred in a country or location that has a state, province, or sub- country code named in code source 22. If not required by this implementation guide, do not send. Example REFLUXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification LU Location Number REF-02 127 Auto Accident State or Province 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 Usage notes Values in this field must be valid codes found in code source 22. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 86/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Claim Identifier For Transmission Intermediaries To specify identifying information Usage notes Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send. Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish. Example REFD9XXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Usage notes Number assigned by clearinghouse, van, etc. D9 Claim Number REF-02 127 Value Added Network 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 Usage notes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 87/579 The value carried in this element is limited to a maximum of 20 positions. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 88/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Demonstration Project Identifier To specify identifying information Usage notes Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and/or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send. Example REFP4XXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification P4 Project Code REF-02 127 Demonstration Project 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 89/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Investigational Device Exemption Number To	Health Partner Plans 837 Health Care Claim_ Institutional.pdf
Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 86/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Claim Identifier For Transmission Intermediaries To specify identifying information Usage notes Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send. Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish. Example REFD9XXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Usage notes Number assigned by clearinghouse, van, etc. D9 Claim Number REF-02 127 Value Added Network 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 Usage notes 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 87/579 The value carried in this element is limited to a maximum of 20 positions. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 88/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Demonstration Project Identifier To specify identifying information Usage notes Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and/or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send. Example REFP4XXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification P4 Project Code REF-02 127 Demonstration Project 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 89/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Investigational Device Exemption Number To specify identifying information Usage notes Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims. If not required by this implementation guide, do not send. Example REFLXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification LX Qualified Products List REF-02 127 Investigational Device Exemption Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 90/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Medical Record Number To specify identifying information Usage notes Required when the provider needs to identify for future inquiries, the actual medical record of the patient identified in either Loop ID-2010BA or Loop ID-2010CA for this episode of care. If not required by this implementation guide, do not send. Example REFEAXXXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EA Medical Record Identification Number REF-02 127 Medical Record 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 91/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Payer Claim Control Number To specify identifying information Usage notes Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REFF8XXXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number REF-02 127 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 92/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Peer Review Organization (PRO) Approval Number To specify identifying information Usage notes Required when an external Peer Review Organization assigns an Approval Number to services deemed medically necessary by that organization. If not required by this implementation guide, do not send. Example REFG4XX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G4 Peer Review Organization (PRO) Approval Number REF-02 127 Peer Review Authorization 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 93/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Prior Authorization To specify identifying information Usage notes Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Required when an authorization number is assigned by the payer or UMO AND the services on this claim were preauthorized. If not required by this implementation guide, do not send. Example REFG1XXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Prior Authorization 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 94/579 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 95/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Referral Number To specify identifying information Usage notes Required when a referral number is assigned by the payer or Utilization Management Organization (UMO) AND a referral is involved. If not required by this implementation guide, do not send. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Example REF9FXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Referral 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 96/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Repriced Claim Number To specify identifying information Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. Example REF9AXXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9A Repriced Claim Reference Number REF-02 127 Repriced Claim Reference 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 1/30/25, 11:52	Health Partner Plans 837 Health Care Claim_ Institutional.pdf
Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Prior Authorization 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 94/579 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 95/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Referral Number To specify identifying information Usage notes Required when a referral number is assigned by the payer or Utilization Management Organization (UMO) AND a referral is involved. If not required by this implementation guide, do not send. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Example REF9FXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Referral 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 96/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Repriced Claim Number To specify identifying information Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. Example REF9AXXXXX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9A Repriced Claim Reference Number REF-02 127 Repriced Claim Reference 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 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 97/579 REF 1800 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > REF Service Authorization Exception Code To specify identifying information Usage notes Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send. Example REF4NX~ Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 4N Special Payment Reference Number REF-02 127 Service Authorization Exception 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 Usage notes Allowable values for this element are: 1 Immediate/Urgent Care 2 Services Rendered in a Retroactive Period 3 Emergency Care 4 Client has Temporary Medicaid 5 Request from County for Second Opinion to Determine if Recipient Can Work 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 98/579 6 Request for Override Pending 7 Special Handling 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 99/579 K3 1850 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > K3 File Information To transmit a fixed-format record or matrix contents Usage notes Required when ALL of the following conditions are met: A regulatory agency concludes it must use the K3 to meet an emergency legislative requirement; The administering regulatory agency or other state organization has completed each one of the following steps: contacted the X12N workgroup, requested a review of the K3 data requirement to ensure there is not an existing method within the implementation guide to meet this requirement X12N determines that there is no method to meet the requirement. If not required by this implementation guide, do not send. At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used : The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment. X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s). Example K3XXXXXX~ Max use 10 Optional K3-01 449 Fixed Format Information Min 1 Max 80 String (AN) Required Data in fixed format agreed upon by sender and receiver 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 100/579 NTE 1900 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > NTE Billing Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. If not required by this implementation guide, do not send. Example NTEADDXX~ Variants (all may be used) NTE Claim Note Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ADD Additional Information NTE-02 352 Billing Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 101/579 NTE 1900 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > NTE Claim Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. OR Required when in the judgment of the provider, narrative information from the forms "Home Health Certification and Plan of Treatment" or "Medical Update and Patient Information" is needed to substantiate home health services. If not required by this implementation guide, do not send. The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.; Example NTERLHXXXXX~ Variants (all may be used) NTE Billing Note Max use 10 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ALG Allergies DCP Goals, Rehabilitation Potential, or Discharge Plans DGN Diagnosis Description DME Durable Medical Equipment (DME) and Supplies MED Medications NTR Nutritional Requirements ODT Orders for Disciplines and Treatments RHB Functional Limitations, Reason Homebound, or Both RLH Reasons Patient Leaves Home RNH Times and Reasons Patient Not at Home SET Unusual Home, Social Environment, or Both SFM Safety Measures SPT Supplementary Plan of Treatment UPI Updated Information NTE-02 352 Claim Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 102/579 CRC 2200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CRC EPSDT Referral To supply information on conditions Usage notes Required on Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim. If not required by this implementation guide, do not send. Example CRCZZYAVXXXX~ Max use 1 Optional CRC-01 1136 Code Qualifier Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. ZZ Mutually Defined EPSDT Screening referral information. CRC-02 1073 Certification Condition Code Applies Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Usage notes The response answers the question: Was an EPSDT referral given to the patient? N No If no, then choose "NU" in CRC03 indicating no referral given. Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC05. AV Available - Not Used Patient refused referral. NU Not Used This conditioner indicator must be used when the submitter answers "N" in CRC02. S2 Under Treatment Patient is currently under treatment for referred diagnostic or corrective health problem. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 103/579 ST New Services Requested Patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals). OR Patient is scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).; CRC-04 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 104/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Admitting Diagnosis To supply information related to the delivery of health care Usage notes Required when claim involves an inpatient admission. If not required by this implementation guide, do not send.; Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI*BJ>XXX~ Variants (all may be used) HI Condition Information HI Diagnosis Related Group (DRG) Information HI External	Health Partner Plans 837 Health Care Claim_ Institutional.pdf
Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 102/579 CRC 2200 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > CRC EPSDT Referral To supply information on conditions Usage notes Required on Early & Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim. If not required by this implementation guide, do not send. Example CRCZZYAVXXXX~ Max use 1 Optional CRC-01 1136 Code Qualifier Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. ZZ Mutually Defined EPSDT Screening referral information. CRC-02 1073 Certification Condition Code Applies Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Usage notes The response answers the question: Was an EPSDT referral given to the patient? N No If no, then choose "NU" in CRC03 indicating no referral given. Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC05. AV Available - Not Used Patient refused referral. NU Not Used This conditioner indicator must be used when the submitter answers "N" in CRC02. S2 Under Treatment Patient is currently under treatment for referred diagnostic or corrective health problem. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 103/579 ST New Services Requested Patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals). OR Patient is scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).; CRC-04 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 104/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Admitting Diagnosis To supply information related to the delivery of health care Usage notes Required when claim involves an inpatient admission. If not required by this implementation guide, do not send.; Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HIBJ>XXX~ Variants (all may be used) HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABJ International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BJ International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis C022-02 1271 Admitting Diagnosis Code Min 1 Max 30 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 105/579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 106/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Condition Information To supply information related to the delivery of health care Usage notes Required when there is a Condition Code that applies to this claim. If not required by this implementation guide, do not send. Example HIBG>XBG>XXXBG>XXBG>XBG>XBG>XXXXXXBG>XXXX XBG>XBG>XXXXXXBG>XXXBG>XXXXBG>XXX~ Variants (all may be used) HI Admitting Diagnosis HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 107/579 Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 108/579 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 109/579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 110/579 Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation	Health Partner Plans 837 Health Care Claim_ Institutional.pdf
C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 109/579 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 110/579 Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 111/579 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 112/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI Diagnosis Related Group (DRG) Information To supply information related to the delivery of health care Usage notes Required when an inpatient hospital is under DRG contract with a payer and the contract requires the provider to identify the DRG to the payer. If not required by this implementation guide, do not send. Example HIDR>XX~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. DR Diagnosis Related Group (DRG) C022-02 1271 Diagnosis Related Group (DRG) Code String (AN) Required Min 1 Max 30 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 113/579 HI 2310 Detail > Billing Provider Hierarchical Level Loop > Subscriber Hierarchical Level Loop > Claim Information Loop > HI External Cause of Injury To supply information related to the delivery of health care Usage notes Required when an external Cause of Injury is needed to describe an injury, poisoning, or adverse effect. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. In order to fully describe an injury using ICD-10-CM, it will be necessary to report a series of 3 external cause of injury codes. Example HIBN>XXXXX>>>>>>>WABN>XXXXXX>>>>>>>NBN>XXX>>>> >>>YBN>XXXX>>>>>>>WABN>XXXXXX>>>>>>>NBN>XXXX>> >>>>>NBN>XXXXX>>>>>>>YBN>XXXX>>>>>>>WABN>XX>>> >>>>UBN>XXX>>>>>>>YABN>XXX>>>>>>>W*ABN>XX>>>>>> >Y~ Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 114/579 the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 115/579 OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new	Health Partner Plans 837 Health Care Claim_ Institutional.pdf
would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 115/579 OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 116/579 BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 117/579 ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 118/579 This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 119/579 If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 120/579 The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes	Health Partner Plans 837 Health Care Claim_ Institutional.pdf
of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 119/579 If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 120/579 The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 121/579 OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 122/579 BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 123/579 ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code 1/30/25, 11:52 AM Health Partner Plans 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-institutional-x223a3/01H16H3T6ZSQSBCEV8FBKSZ4YX 124/579 This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and	Health Partner Plans 837 Health Care Claim_ Institutional.pdf

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