X12 835 Health Care Claim Payment/Advice (X221A1)

X12 Release 5010

Delimiters

• ~ Segment
• * Element
• > Component
• ^ Repetition

ISA Interchange Control Header

Required · Max use 1

ISA-01 · I01 · Authorization Information Qualifier · Required · Identifier (ID)

• 00: No Authorization Information Present (No Meaningful Information in I02)

ISA-02 · I02 · Authorization Information · Required · String (AN) · Min 10 Max 10

ISA-03 · I03 · Security Information Qualifier · Required · Identifier (ID)

• 00: No Security Information Present (No Meaningful Information in I04)

ISA-04 · I04 · Security Information · Required · String (AN) · Min 10 Max 10

ISA-05 · I05 · Interchange ID Qualifier · Required · Identifier (ID) · Min 2 Max 2

Codes

• 01: Duns (Dun & Bradstreet)
• 02: SCAC (Standard Carrier Alpha Code)
• 03: FMC (Federal Maritime Commission)
• 04: IATA (International Air Transport Association)
• 07: Global Location Number (GLN)
• 08: UCC EDI Communications ID (Comm ID)
• 09: X.121 (CCITT)
• 10: Department of Defense (DoD) Activity Address Code
• 11: DEA (Drug Enforcement Administration)
• 12: Phone (Telephone Companies)
• 13: UCS Code (The UCS Code is a Code Used for UCS Transmissions; it includes the Area Code and Telephone Number of a Modem; it Does Not Include Punctuation, Blanks or Access Code)
• 14: Duns Plus Suffix
• 15: Petroleum Accountants Society of Canada Company Code
• 16: Duns Number With 4-Character Suffix
• 17: American Bankers Association (ABA) Transit Routing Number (Including Check Digit, 9 Digit)
• 18: Association of American Railroads (AAR) Standard Distribution Code
• 19: EDI Council of Australia (EDICA) Communications ID Number (COMM ID)
• 20: Health Industry Number (HIN)
• 21: Integrated Postsecondary Education Data System, or (IPEDS)
• 22: Federal Interagency Commission on Education, or FICE
• 23: National Center for Education Statistics Common Core of Data 12-Digit Number for Pre-K-Grade 12 Institutes, or NCES
• 24: The College Board's Admission Testing Program 4-Digit Code of Postsecondary Institutes, or ATP
• 25: ACT, Inc. 4-Digit Code of Postsecondary Institutions.
• 26: Statistics of Canada List of Postsecondary Institutions
• 27: Carrier Identification Number as assigned by Health Care Financing Administration (HCFA)
• 28: Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA)
• 29: Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA)
• 30: U.S. Federal Tax Identification Number
• 31: Jurisdiction Identification Number Plus 4 as assigned by the International Association of Industrial Accident Boards and Commissions (IAIABC)
• 32: U.S. Federal Employer Identification Number (FEIN)
• 33: National Association of Insurance Commissioners Company Code (NAIC)
• 34: Medicaid Provider and Supplier Identification Number as assigned by individual State Medicaid Agencies in conjunction with Health Care Financing Administration (HCFA)
• 35: Statistics Canada Canadian College Student Information System Institution Codes
• 36: Statistics Canada University Student Information System Institution Codes
• 37: Society of Property Information Compilers and Analysts
• 38: The College Board and ACT, Inc. 6-Digit Code List of Secondary Institutions
• AM: Association Mexicana del Codigo de Producto (AMECOP) Communication ID
• NR: National Retail Merchants Association (NRMA) - Assigned
• SA: User Identification Number as assigned by the Safety and Fitness Electronic Records (SAFER) System
• SN: Standard Address Number
• ZZ: Mutually Defined

ISA-06 · I06 · Interchange Sender ID · Required · String (AN) · Min 15 Max 15

ISA-07 · I05 · Interchange ID Qualifier · Required · Identifier (ID) · Min 2 Max 2

Codes

• 01: Duns (Dun & Bradstreet)
• 02: SCAC (Standard Carrier Alpha Code)
• 03: FMC (Federal Maritime Commission)
• 04: IATA (International Air Transport Association)
• 07: Global Location Number (GLN)
• 08: UCC EDI Communications ID (Comm ID)
• 09: X.121 (CCITT)
• 10: Department of Defense (DoD) Activity Address Code
• 11: DEA (Drug Enforcement Administration)
• 12: Phone (Telephone Companies)
• 13: UCS Code (The UCS Code is a Code Used for UCS Transmissions; it includes the Area Code and Telephone Number of a Modem; it Does Not Include Punctuation, Blanks or Access Code)
• 14: Duns Plus Suffix
• 15: Petroleum Accountants Society of Canada Company Code
• 16: Duns Number With 4-Character Suffix
• 17: American Bankers Association (ABA) Transit Routing Number (Including Check Digit, 9 Digit)
• 18: Association of American Railroads (AAR) Standard Distribution Code
• 19: EDI Council of Australia (EDICA) Communications ID Number (COMM ID)
• 20: Health Industry Number (HIN)
• 21: Integrated Postsecondary Education Data System, or (IPEDS)
• 22: Federal Interagency Commission on Education, or FICE
• 23: National Center for Education Statistics Common Core of Data 12-Digit Number for Pre-K-Grade 12 Institutes, or NCES
• 24: The College Board's Admission Testing Program 4-Digit Code of Postsecondary Institutes, or ATP
• 25: ACT, Inc. 4-Digit Code of Postsecondary Institutions.
• 26: Statistics of Canada List of Postsecondary Institutions
• 27: Carrier Identification Number as assigned by Health Care Financing Administration (HCFA)
• 28: Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA)
• 29: Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA)
• 30: U.S. Federal Tax Identification Number
• 31: Jurisdiction Identification Number Plus 4 as assigned by the International Association of Industrial Accident Boards and Commissions (IAIABC)
• 32: U.S. Federal Employer Identification Number (FEIN)
• 33: National Association of Insurance Commissioners Company Code (NAIC)
• 34: Medicaid Provider and Supplier Identification Number as assigned by individual State Medicaid Agencies in conjunction with Health Care Financing Administration (HCFA)
• 35: Statistics Canada Canadian College Student Information System Institution Codes
• 36: Statistics Canada University Student Information System Institution Codes
• 37: Society of Property Information Compilers and Analysts
• 38: The College Board and ACT, Inc. 6-Digit Code List of Secondary Institutions
• AM: Association Mexicana del Codigo de Producto (AMECOP) Communication ID
• NR: National Retail Merchants Association (NRMA) - Assigned
• SA: User Identification Number as assigned by the Safety and Fitness Electronic Records (SAFER) System
• SN: Standard Address Number
• ZZ: Mutually Defined

ISA-08 · I07 · Interchange Receiver ID · Required · String (AN) · Min 15 Max 15

ISA-09 · I08 · Interchange Date · Required · Date (DT) · YYMMDD format

ISA-10 · I09 · Interchange Time · Required · Time (TM) · HHMM format

ISA-11 · I65 · Repetition Separator · Required · String (AN) · Min 1 Max 1

• ^: Repetition Separator

ISA-12 · I11 · Interchange Control Version Number · Required · Identifier (ID)

• 00501: Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003

ISA-13 · I12 · Interchange Control Number · Required · Numeric (N0) · Min 9 Max 9

ISA-14 · I13 · Acknowledgment Requested · Required · Identifier (ID) · Min 1 Max 1

• 0: No Interchange Acknowledgment Requested
• 1: Interchange Acknowledgment Requested (TA1)

ISA-15 · I14 · Interchange Usage Indicator · Required · Identifier (ID) · Min 1 Max 1

• I: Information
• P: Production Data
• T: Test Data

ISA-16 · I15 · Component Element Separator · Required · String (AN) · Min 1 Max 1

• >: Component Element Separator

GS Functional Group Header

Required · Max use 1

GS-01 · 479 · Functional Identifier Code · Required · Identifier (ID)

• HP: Health Care Claim Payment/Advice (835)

GS-02 · 142 · Application Sender's Code · Required · String (AN) · Min 2 Max 15

GS-03 · 124 · Application Receiver's Code · Required · String (AN) · Min 2 Max 15

GS-04 · 373 · Date · Required · Date (DT) · CCYYMMDD format

GS-05 · 337 · Time · Required · Time (TM) · HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

GS-06 · 28 · Group Control Number · Required · Numeric (N0) · Min 1 Max 9

GS-07 · 455 · Responsible Agency Code · Required · Identifier (ID) · Min 1 Max 2

• T: Transportation Data Coordinating Committee (TDCC)
• X: Accredited Standards Committee X12

GS-08 · 480 · Version / Release / Industry Identifier Code · Required · String (AN)

005010X221A1

Heading

0100 Heading > ST

ST Transaction Set Header

Required · Max use 1

ST-01 · 143 · Transaction Set Identifier Code · Required · Identifier (ID)

• 835: Health Care Claim Payment/Advice

ST-02 · 329 · Transaction Set Control Number · Required · Numeric (N) · Min 4 Max 9

0200 Heading > BPR

BPR Financial Information

Required · Max use 1

If either Depository Financial Institution (DFI) Identification Number Qualifier (BPR-06) or Sender DFI Identifier (BPR-07) is present, then the other is required

If Account Number Qualifier (BPR-08) is present, then Sender Bank Account Number (BPR-09) is required

If either Depository Financial Institution (DFI) Identification Number Qualifier (BPR-12) or Receiver or Provider Bank ID Number (BPR-13) is present, then the other is required

If Account Number Qualifier (BPR-14) is present, then Receiver or Provider Account Number (BPR-15) is required

BPR-01 · 305 · Transaction Handling Code · Required · Identifier (ID)

• C: Payment Accompanies Remittance Advice
• D: Make Payment Only
• H: Notification Only
• I: Remittance Information Only
• P: Prenotification of Future Transfers
• U: Split Payment and Remittance
• X: Handling Party's Option to Split Payment and Remittance

BPR-02 · 782 · Total Actual Provider Payment Amount · Required · Decimal number (R) · Min 1 Max 15

BPR-03 · 478 · Credit or Debit Flag Code · Required · Identifier (ID)

• C: Credit
• D: Debit

BPR-04 · 591 · Payment Method Code · Required · Identifier (ID)

• ACH: Automated Clearing House (ACH)
• BOP: Financial Institution Option
• CHK: Check
• FWT: Federal Reserve Funds/Wire Transfer - Nonrepetitive
• NON: Non-Payment Data

BPR-05 · 812 · Payment Format Code · Optional · Identifier (ID)

• CCP: Cash Concentration/Disbursement plus Addenda (CCD+) (ACH)
• CTX: Corporate Trade Exchange (CTX) (ACH)

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

• 01: ABA Transit Routing Number Including Check Digits (9 digits)
• 04: Canadian Bank Branch and Institution Number

BPR-07 · 507 · Sender DFI Identifier · Optional · String (AN) · Min 3 Max 12

BPR-08 · 569 · Account Number Qualifier · Optional · Identifier (ID)

• DA: Demand Deposit

BPR-09 · 508 · Sender Bank Account Number · Optional · String (AN) · Min 1 Max 35

BPR-10 · 509 · Payer Identifier · Optional · String (AN) · Min 10 Max 10

BPR-11 · 510 · Originating Company Supplemental Code · Optional · String (AN) · Min 9 Max 9

BPR-12 · 506 · Depository Financial Institution (DFI) Identification Number Qualifier · Optional · Identifier (ID)

• 01: ABA Transit Routing Number Including Check Digits (9 digits)
• 04: Canadian Bank Branch and Institution Number

BPR-13 · 507 · Receiver or Provider Bank ID Number · Optional · String (AN) · Min 3 Max 12

BPR-14 · 569 · Account Number Qualifier · Optional · Identifier (ID)

• DA: Demand Deposit
• SG: Savings

BPR-15 · 508 · Receiver or Provider Account Number · Optional · String (AN) · Min 1 Max 35

BPR-16 · 373 · Check Issue or EFT Effective Date · Required · Date (DT) · CCYYMMDD format

0400 Heading > TRN

TRN Reassociation Trace Number

Required · Max use 1

TRN-01 · 481 · Trace Type Code · Required · Identifier (ID)

• 1: Current Transaction Trace Numbers

TRN-02 · 127 · Check or EFT Trace Number · Required · String (AN) · Min 1 Max 50

TRN-03 · 509 · Payer Identifier · Required · String (AN) · Min 10 Max 10

TRN-04 · 127 · Originating Company Supplemental Code · Optional · String (AN) · Min 1 Max 50

0500 Heading > CUR

CUR Foreign Currency Information

Optional · Max use 1

CUR-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• PR: Payer

CUR-02 · 100 · Currency Code · Required · Identifier (ID) · Min 3 Max 3

0600 Heading > REF

REF Receiver Identification

Optional · Max use 1

Variants (all may be used)

REFVersion Identification

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• EV: Receiver Identification Number

REF-02 · 127 · Receiver Identifier · Required · String (AN) · Min 1 Max 50

0600 Heading > REF

REF Version Identification

Optional · Max use 1

Variants (all may be used)

REFReceiver Identification

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• F2: Version Code - Local

REF-02 · 127 · Version Identification Code · Required · String (AN) · Min 1 Max 50

0700 Heading > DTM

DTM Production Date

Optional · Max use 1

DTM-01 · 374 · Date Time Qualifier · Required · Identifier (ID)

• 405: Production

DTM-02 · 373 · Production Date · Required · Date (DT) · CCYYMMDD format

1000A Payer Identification Loop Required Max 1

Variants (all may be used)

Payee Identification Loop

0800 Heading > Payer Identification Loop > N1

N1 Payer Identification

Required · Max use 1

If either Identification Code Qualifier (N1-03) or Payer Identifier (N1-04) is present, then the other is required

N1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• PR: Payer

N1-02 · 93 · Payer Name · Required · String (AN) · Min 1 Max 60

N1-03 · 66 · Identification Code Qualifier · Optional · Identifier (ID)

• XV: Centers for Medicare and Medicaid Services PlanID

N1-04 · 67 · Payer Identifier · Optional · String (AN) · Min 2 Max 80

1000 Heading > Payer Identification Loop > N3

N3 Payer Address

Required · Max use 1

N3-01 · 166 · Payer Address Line · Required · String (AN) · Min 1 Max 55

N3-02 · 166 · Payer Address Line · Optional · String (AN) · Min 1 Max 55

1100 Heading > Payer Identification Loop > N4

N4 Payer City, State, ZIP Code

Required · Max use 1

Only one of Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present

If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required

N4-01 · 19 · Payer City Name · Required · String (AN) · Min 2 Max 30

N4-02 · 156 · Payer State Code · Optional · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Payer Postal Zone or ZIP Code · Optional · Identifier (ID) · Min 3 Max 15

N4-04 · 26 · Country Code · Optional · Identifier (ID) · Min 2 Max 3

N4-07 · 1715 · Country Subdivision Code · Optional · Identifier (ID) · Min 1 Max 3

1200 Heading > Payer Identification Loop > REF

REF Additional Payer Identification

Optional · Max use 4

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 2U: Payer Identification Number
• EO: Submitter Identification Number
• HI: Health Industry Number (HIN)
• NF: National Association of Insurance Commissioners (NAIC) Code

REF-02 · 127 · Additional Payer Identifier · Required · String (AN) · Min 1 Max 50

1300 Heading > Payer Identification Loop > PER

PER Payer Business Contact Information

Optional · Max use 1

Variants (all may be used)

PERPayer Technical Contact InformationPERPayer WEB Site

If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required

If either Communication Number Qualifier (PER-05) or Payer Contact Communication Number (PER-06) is present, then the other is required

If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required

PER-01 · 366 · Contact Function Code · Required · Identifier (ID)

• CX: Payers Claim Office

PER-02 · 93 · Payer Contact Name · Optional · String (AN) · Min 1 Max 60

PER-03 · 365 · Communication Number Qualifier · Optional · Identifier (ID)

• EM: Electronic Mail
• FX: Facsimile
• TE: Telephone

PER-04 · 364 · Payer Contact Communication Number · Optional · String (AN) · Min 1 Max 256

PER-05 · 365 · Communication Number Qualifier · Optional · Identifier (ID)

• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• TE: Telephone

PER-06 · 364 · Payer Contact Communication Number · Optional · String (AN) · Min 1 Max 256

PER-07 · 365 · Communication Number Qualifier · Optional · Identifier (ID)

• EX: Telephone Extension

PER-08 · 364 · Payer Contact Communication Number · Optional · String (AN) · Min 1 Max 256

1300 Heading > Payer Identification Loop > PER

PER Payer Technical Contact Information

Required · Max use >1

Variants (all may be used)

PERPayer Business Contact InformationPERPayer WEB Site

If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required

If either Communication Number Qualifier (PER-05) or Payer Technical Contact Communication Number (PER-06) is present, then the other is required

If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required

PER-01 · 366 · Contact Function Code · Required · Identifier (ID)

• BL: Technical Department

PER-02 · 93 · Payer Technical Contact Name · Optional · String (AN) · Min 1 Max 60

PER-03 · 365 · Communication Number Qualifier · Optional · Identifier (ID)

• EM: Electronic Mail
• TE: Telephone
• UR: Uniform Resource Locator (URL)

PER-04 · 364 · Payer Contact Communication Number · Optional · String (AN) · Min 1 Max 256

PER-05 · 365 · Communication Number Qualifier · Optional · Identifier (ID)

• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• TE: Telephone
• UR: Uniform Resource Locator (URL)

PER-06 · 364 · Payer Technical Contact Communication Number · Optional · String (AN) · Min 1 Max 256

PER-07 · 365 · Communication Number Qualifier · Optional · Identifier (ID)

• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• UR: Uniform Resource Locator (URL)

PER-08 · 364 · Payer Contact Communication Number · Optional · String (AN) · Min 1 Max 256

1300 Heading > Payer Identification Loop > PER

PER Payer WEB Site

Optional · Max use 1

Variants (all may be used)

PERPayer Business Contact InformationPERPayer Technical Contact Information

PER-01 · 366 · Contact Function Code · Required · Identifier (ID)

• IC: Information Contact

PER-03 · 365 · Communication Number Qualifier · Required · Identifier (ID)

• UR: Uniform Resource Locator (URL)

PER-04 · 364 · Communication Number · Required · String (AN) · Min 1 Max 256

1000B Payee Identification Loop Required Max 1

Variants (all may be used)

Payer Identification Loop

0800 Heading > Payee Identification Loop > N1

N1 Payee Identification

Required · Max use 1

N1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• PE: Payee

N1-02 · 93 · Payee Name · Required · String (AN) · Min 1 Max 60

N1-03 · 66 · Identification Code Qualifier · Required · Identifier (ID)

• XV: Centers for Medicare and Medicaid Services PlanID
• XX: Centers for Medicare and Medicaid Services National Provider Identifier

N1-04 · 67 · Payee Identification Code · Required · String (AN) · Min 2 Max 80

1000 Heading > Payee Identification Loop > N3

N3 Payee Address

Optional · Max use 1

N3-01 · 166 · Payee Address Line · Required · String (AN) · Min 1 Max 55

N3-02 · 166 · Payee Address Line · Optional · String (AN) · Min 1 Max 55

1100 Heading > Payee Identification Loop > N4

N4 Payee City, State, ZIP Code

Optional · Max use 1

Only one of Payee State Code (N4-02) or Country Subdivision Code (N4-07) may be present

If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required

N4-01 · 19 · Payee City Name · Required · String (AN) · Min 2 Max 30

N4-02 · 156 · Payee State Code · Optional · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Payee Postal Zone or ZIP Code · Optional · Identifier (ID) · Min 3 Max 15

N4-04 · 26 · Country Code · Optional · Identifier (ID) · Min 2 Max 3

N4-07 · 1715 · Country Subdivision Code · Optional · Identifier (ID) · Min 1 Max 3

1200 Heading > Payee Identification Loop > REF

REF Payee Additional Identification

Optional · Max use >1

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 0B: State License Number
• D3: National Council for Prescription Drug Programs Pharmacy Number
• PQ: Payee Identification

REF-02 · 127 · Additional Payee Identifier · Required · String (AN) · Min 1 Max 50

1400 Heading > Payee Identification Loop > RDM

RDM Remittance Delivery Method

Optional · Max use 1

RDM-01 · 756 · Report Transmission Code · Required · Identifier (ID)

• BM: By Mail
• EM: E-Mail
• FT: File Transfer
• OL: On-Line

RDM-02 · 93 · Name · Optional · String (AN) · Min 1 Max 60

RDM-03 · 364 · Communication Number · Optional · String (AN) · Min 1 Max 256

Detail

2000 Header Number Loop Optional Max >1

0030 Detail > Header Number Loop > LX

LX Header Number

Required · Max use 1

LX-01 · 554 · Assigned Number · Required · Numeric (N0) · Min 1 Max 6

0050 Detail > Header Number Loop > TS3

TS3 Provider Summary Information

Optional · Max use 1

TS3-01 · 127 · Provider Identifier · Required · String (AN) · Min 1 Max 50

TS3-02 · 1331 · Facility Type Code · Required · String (AN) · Min 1 Max 2

TS3-03 · 373 · Fiscal Period Date · Required · Date (DT) · CCYYMMDD format

TS3-04 · 380 · Total Claim Count · Required · Decimal number (R) · Min 1 Max 15

TS3-05 · 782 · Total Claim Charge Amount · Required · Decimal number (R) · Min 1 Max 15

TS3-13 · 782 · Total MSP Payer Amount · Optional · Decimal number (R) · Min 1 Max 15

TS3-15 · 782 · Total Non-Lab Charge Amount · Optional · Decimal number (R) · Min 1 Max 15

TS3-17 · 782 · Total HCPCS Reported Charge Amount · Optional · Decimal number (R) · Min 1 Max 15

TS3-18 · 782 · Total HCPCS Payable Amount · Optional · Decimal number (R) · Min 1 Max 15

TS3-20 · 782 · Total Professional Component Amount · Optional · Decimal number (R) · Min 1 Max 15

TS3-21 · 782 · Total MSP Patient Liability Met Amount · Optional · Decimal number (R) · Min 1 Max 15

TS3-22 · 782 · Total Patient Reimbursement Amount · Optional · Decimal number (R) · Min 1 Max 15

TS3-23 · 380 · Total PIP Claim Count · Optional · Decimal number (R) · Min 1 Max 15

TS3-24 · 782 · Total PIP Adjustment Amount · Optional · Decimal number (R) · Min 1 Max 15

0070 Detail > Header Number Loop > TS2

TS2 Provider Supplemental Summary Information

Optional · Max use 1

TS2-01 · 782 · Total DRG Amount · Optional · Decimal number (R) · Min 1 Max 15

TS2-02 · 782 · Total Federal Specific Amount · Optional · Decimal number (R) · Min 1 Max 15

TS2-03 · 782 · Total Hospital Specific Amount · Optional · Decimal number (R) · Min 1 Max 15

TS2-04 · 782 · Total Disproportionate Share Amount · Optional · Decimal number (R) · Min 1 Max 15

TS2-05 · 782 · Total Capital Amount · Optional · Decimal number (R) · Min 1 Max 15

TS2-06 · 782 · Total Indirect Medical Education Amount · Optional · Decimal number (R) · Min 1 Max 15

TS2-07 · 380 · Total Outlier Day Count · Optional · Decimal number (R) · Min 1 Max 15

TS2-08 · 782 · Total Day Outlier Amount · Optional · Decimal number (R) · Min 1 Max 15

TS2-09 · 782 · Total Cost Outlier Amount · Optional · Decimal number (R) · Min 1 Max 15

TS2-10 · 380 · Average DRG Length of Stay · Optional · Decimal number (R) · Min 1 Max 15

TS2-11 · 380 · Total Discharge Count · Optional · Decimal number (R) · Min 1 Max 15

TS2-12 · 380 · Total Cost Report Day Count · Optional · Decimal number (R) · Min 1 Max 15

TS2-13 · 380 · Total Covered Day Count · Optional · Decimal number (R) · Min 1 Max 15

TS2-14 · 380 · Total Noncovered Day Count · Optional · Decimal number (R) · Min 1 Max 15

TS2-15 · 782 · Total MSP Pass-Through Amount · Optional · Decimal number (R) · Min 1 Max 15

TS2-16 · 380 · Average DRG weight · Optional · Decimal number (R) · Min 1 Max 15

TS2-17 · 782 · Total PPS Capital FSP DRG Amount · Optional · Decimal number (R) · Min 1 Max 15

TS2-18 · 782 · Total PPS Capital HSP DRG Amount · Optional · Decimal number (R) · Min 1 Max 15

TS2-19 · 782 · Total PPS DSH DRG Amount · Optional · Decimal number (R) · Min 1 Max 15

2100 Claim Payment Information Loop Required Max >1

0100 Detail > Header Number Loop > Claim Payment Information Loop > CLP

CLP Claim Payment Information

Required · Max use 1

CLP-01 · 1028 · Patient Control Number · Required · String (AN) · Min 1 Max 38

CLP-02 · 1029 · Claim Status Code · Required · Identifier (ID)

• 1: Processed as Primary
• 2: Processed as Secondary
• 3: Processed as Tertiary
• 4: Denied
• 19: Processed as Primary, Forwarded to Additional Payer(s)
• 20: Processed as Secondary, Forwarded to Additional Payer(s)
• 21: Processed as Tertiary, Forwarded to Additional Payer(s)
• 22: Reversal of Previous Payment
• 23: Not Our Claim, Forwarded to Additional Payer(s)
• 25: Predetermination Pricing Only - No Payment

CLP-03 · 782 · Total Claim Charge Amount · Required · Decimal number (R) · Min 1 Max 15

CLP-04 · 782 · Claim Payment Amount · Required · Decimal number (R) · Min 1 Max 15

CLP-05 · 782 · Patient Responsibility Amount · Optional · Decimal number (R) · Min 1 Max 15

CLP-06 · 1032 · Claim Filing Indicator Code · Required · Identifier (ID)

• 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
• 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
• TV: Title V
• VA: Veterans Affairs Plan
• WC: Workers' Compensation Health Claim
• ZZ: Mutually Defined

CLP-07 · 127 · Payer Claim Control Number · Required · String (AN) · Min 1 Max 50

CLP-08 · 1331 · Facility Type Code · Optional · String (AN) · Min 1 Max 2

CLP-09 · 1325 · Claim Frequency Code · Optional · Identifier (ID) · Min 1 Max 1

CLP-11 · 1354 · Diagnosis Related Group (DRG) Code · Optional · Identifier (ID) · Min 1 Max 4

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

CLP-13 · 954 · Discharge Fraction · Optional · Decimal number (R) · Min 1 Max 10

0200 Detail > Header Number Loop > Claim Payment Information Loop > CAS

CAS Claim Adjustment

Optional · Max use 99

If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required

If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required

If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required

If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required

If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required

If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required

If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required

If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required

If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required

If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required

If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required

If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required

If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required

If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required

If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required

CAS-01 · 1033 · Claim Adjustment Group Code · Required · Identifier (ID)

• CO: Contractual Obligations
• OA: Other adjustments
• PI: Payor Initiated Reductions
• PR: Patient Responsibility

CAS-02 · 1034 · Adjustment Reason Code · Required · Identifier (ID) · Min 1 Max 5

CAS-03 · 782 · Adjustment Amount · Required · Decimal number (R) · Min 1 Max 15

CAS-04 · 380 · Adjustment Quantity · Optional · Decimal number (R) · Min 1 Max 15

CAS-05 · 1034 · Adjustment Reason Code · Optional · Identifier (ID) · Min 1 Max 5

CAS-06 · 782 · Adjustment Amount · Optional · Decimal number (R) · Min 1 Max 15

CAS-07 · 380 · Adjustment Quantity · Optional · Decimal number (R) · Min 1 Max 15

CAS-08 · 1034 · Adjustment Reason Code · Optional · Identifier (ID) · Min 1 Max 5

CAS-09 · 782 · Adjustment Amount · Optional · Decimal number (R) · Min 1 Max 15

CAS-10 · 380 · Adjustment Quantity · Optional · Decimal number (R) · Min 1 Max 15

CAS-11 · 1034 · Adjustment Reason Code · Optional · Identifier (ID) · Min 1 Max 5

CAS-12 · 782 · Adjustment Amount · Optional · Decimal number (R) · Min 1 Max 15

CAS-13 · 380 · Adjustment Quantity · Optional · Decimal number (R) · Min 1 Max 15

CAS-14 · 1034 · Adjustment Reason Code · Optional · Identifier (ID) · Min 1 Max 5

CAS-15 · 782 · Adjustment Amount · Optional · Decimal number (R) · Min 1 Max 15

CAS-16 · 380 · Adjustment Quantity · Optional · Decimal number (R) · Min 1 Max 15

CAS-17 · 1034 · Adjustment Reason Code · Optional · Identifier (ID) · Min 1 Max 5

CAS-18 · 782 · Adjustment Amount · Optional · Decimal number (R) · Min 1 Max 15

CAS-19 · 380 · Adjustment Quantity · Optional · Decimal number (R) · Min 1 Max 15

0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1

NM1 Corrected Patient/Insured Name

Optional · Max use 1

Variants (all may be used)

NM1Corrected Priority Payer NameNM1Crossover Carrier NameNM1Insured NameNM1Other Subscriber NameNM1Patient NameNM1Service Provider Name

If either Identification Code Qualifier (NM1-08) or Corrected Insured Identification Indicator (NM1-09) is present, then the other is required

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• 74: Corrected Insured

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 1: Person
• 2: Non-Person Entity

NM1-03 · 1035 · Corrected Patient or Insured Last Name · Optional · String (AN) · Min 1 Max 60

NM1-04 · 1036 · Corrected Patient or Insured First Name · Optional · String (AN) · Min 1 Max 35

NM1-05 · 1037 · Corrected Patient or Insured Middle Name · Optional · String (AN) · Min 1 Max 25

NM1-07 · 1039 · Corrected Patient or Insured Name Suffix · Optional · String (AN) · Min 1 Max 10

NM1-08 · 66 · Identification Code Qualifier · Optional · Identifier (ID)

• C: Insured's Changed Unique Identification Number

NM1-09 · 67 · Corrected Insured Identification Indicator · Optional · String (AN) · Min 2 Max 80

0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1

NM1 Corrected Priority Payer Name

Optional · Max use 1

Variants (all may be used)

NM1Corrected Patient/Insured NameNM1Crossover Carrier NameNM1Insured NameNM1Other Subscriber NameNM1Patient NameNM1Service Provider Name

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• PR: Payer

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 2: Non-Person Entity

NM1-03 · 1035 · Corrected Priority Payer Name · Required · String (AN) · Min 1 Max 60

NM1-08 · 66 · Identification Code Qualifier · Required · Identifier (ID)

• AD: Blue Cross Blue Shield Association Plan Code
• FI: Federal Taxpayer's Identification Number
• NI: National Association of Insurance Commissioners (NAIC) Identification
• PI: Payor Identification
• PP: Pharmacy Processor Number
• XV: Centers for Medicare and Medicaid Services PlanID

NM1-09 · 67 · Corrected Priority Payer Identification Number · Required · String (AN) · Min 2 Max 80

0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1

NM1 Crossover Carrier Name

Optional · Max use 1

Variants (all may be used)

NM1Corrected Patient/Insured NameNM1Corrected Priority Payer NameNM1Insured NameNM1Other Subscriber NameNM1Patient NameNM1Service Provider Name

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• TT: Transfer To

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 2: Non-Person Entity

NM1-03 · 1035 · Crossover Carrier Name · Required · String (AN) · Min 1 Max 60

NM1-08 · 66 · Identification Code Qualifier · Required · Identifier (ID)

• AD: Blue Cross Blue Shield Association Plan Code
• FI: Federal Taxpayer's Identification Number
• NI: National Association of Insurance Commissioners (NAIC) Identification
• PI: Payor Identification
• PP: Pharmacy Processor Number
• XV: Centers for Medicare and Medicaid Services PlanID

NM1-09 · 67 · Crossover Carrier Identifier · Required · String (AN) · Min 2 Max 80

0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1

NM1 Insured Name

Optional · Max use 1

Variants (all may be used)

NM1Corrected Patient/Insured NameNM1Corrected Priority Payer NameNM1Crossover Carrier NameNM1Other Subscriber NameNM1Patient NameNM1Service Provider Name

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• IL: Insured or Subscriber

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 1: Person
• 2: Non-Person Entity

NM1-03 · 1035 · Subscriber Last Name · Optional · String (AN) · Min 1 Max 60

NM1-04 · 1036 · Subscriber First Name · Optional · String (AN) · Min 1 Max 35

NM1-05 · 1037 · Subscriber Middle Name or Initial · Optional · String (AN) · Min 1 Max 25

NM1-07 · 1039 · Subscriber Name Suffix · Optional · String (AN) · Min 1 Max 10

NM1-08 · 66 · Identification Code Qualifier · Required · Identifier (ID)

• FI: Federal Taxpayer's Identification Number
• II: Standard Unique Health Identifier for each Individual in the United States
• MI: Member Identification Number

NM1-09 · 67 · Subscriber Identifier · Required · String (AN) · Min 2 Max 80

0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1

NM1 Other Subscriber Name

Optional · Max use 1

Variants (all may be used)

NM1Corrected Patient/Insured NameNM1Corrected Priority Payer NameNM1Crossover Carrier NameNM1Insured NameNM1Patient NameNM1Service Provider Name

If either Identification Code Qualifier (NM1-08) or Other Subscriber Identifier (NM1-09) is present, then the other is required

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• GB: Other Insured

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 1: Person
• 2: Non-Person Entity

NM1-03 · 1035 · Other Subscriber Last Name · Optional · String (AN) · Min 1 Max 60

NM1-04 · 1036 · Other Subscriber First Name · Optional · String (AN) · Min 1 Max 35

NM1-05 · 1037 · Other Subscriber Middle Name or Initial · Optional · String (AN) · Min 1 Max 25

NM1-07 · 1039 · Other Subscriber Name Suffix · Optional · String (AN) · Min 1 Max 10

NM1-08 · 66 · Identification Code Qualifier · Optional · Identifier (ID)

• FI: Federal Taxpayer's Identification Number
• II: Standard Unique Health Identifier for each Individual in the United States
• MI: Member Identification Number

NM1-09 · 67 · Other Subscriber Identifier · Optional · String (AN) · Min 2 Max 80

0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1

NM1 Patient Name

Required · Max use 1

Variants (all may be used)

NM1Corrected Patient/Insured NameNM1Corrected Priority Payer NameNM1Crossover Carrier NameNM1Insured NameNM1Other Subscriber NameNM1Service Provider Name

If either Identification Code Qualifier (NM1-08) or Patient Identifier (NM1-09) is present, then the other is required

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• QC: Patient

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 1: Person

NM1-03 · 1035 · Patient Last Name · Optional · String (AN) · Min 1 Max 60

NM1-04 · 1036 · Patient First Name · Optional · String (AN) · Min 1 Max 35

NM1-05 · 1037 · Patient Middle Name or Initial · Optional · String (AN) · Min 1 Max 25

NM1-07 · 1039 · Patient Name Suffix · Optional · String (AN) · Min 1 Max 10

NM1-08 · 66 · Identification Code Qualifier · Optional · Identifier (ID)

• HN: Health Insurance Claim (HIC) Number
• II: Standard Unique Health Identifier for each Individual in the United States
• MI: Member Identification Number
• MR: Medicaid Recipient Identification Number

NM1-09 · 67 · Patient Identifier · Optional · String (AN) · Min 2 Max 80

0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1

NM1 Service Provider Name

Optional · Max use 1

Variants (all may be used)

NM1Corrected Patient/Insured NameNM1Corrected Priority Payer NameNM1Crossover Carrier NameNM1Insured NameNM1Other Subscriber NameNM1Patient Name

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• 82: Rendering Provider

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 1: Person
• 2: Non-Person Entity

NM1-03 · 1035 · Rendering Provider Last or Organization Name · Optional · String (AN) · Min 1 Max 60

NM1-04 · 1036 · Rendering Provider First Name · Optional · String (AN) · Min 1 Max 35

NM1-05 · 1037 · Rendering Provider Middle Name or Initial · Optional · String (AN) · Min 1 Max 25

NM1-07 · 1039 · Rendering Provider Name Suffix · Optional · String (AN) · Min 1 Max 10

NM1-08 · 66 · Identification Code Qualifier · Required · Identifier (ID)

• BD: Blue Cross Provider Number
• BS: Blue Shield Provider Number
• MC: Medicaid Provider Number
• PC: Provider Commercial Number
• SL: State License Number
• UP: Unique Physician Identification Number (UPIN)
• XX: Centers for Medicare and Medicaid Services National Provider Identifier

NM1-09 · 67 · Rendering Provider Identifier · Required · String (AN) · Min 2 Max 80

0330 Detail > Header Number Loop > Claim Payment Information Loop > MIA

MIA Inpatient Adjudication Information

Optional · Max use 1

MIA-01 · 380 · Covered Days or Visits Count · Required · Decimal number (R) · Min 1 Max 15

MIA-02 · 782 · PPS Operating Outlier Amount · Optional · Decimal number (R) · Min 1 Max 15

MIA-03 · 380 · Lifetime Psychiatric Days Count · Optional · Decimal number (R) · Min 1 Max 15

MIA-04 · 782 · Claim DRG Amount · Optional · Decimal number (R) · Min 1 Max 15

MIA-05 · 127 · Claim Payment Remark Code · Optional · String (AN) · Min 1 Max 50

MIA-06 · 782 · Claim Disproportionate Share Amount · Optional · Decimal number (R) · Min 1 Max 15

MIA-07 · 782 · Claim MSP Pass-through Amount · Optional · Decimal number (R) · Min 1 Max 15

MIA-08 · 782 · Claim PPS Capital Amount · Optional · Decimal number (R) · Min 1 Max 15

MIA-09 · 782 · PPS-Capital FSP DRG Amount · Optional · Decimal number (R) · Min 1 Max 15

MIA-10 · 782 · PPS-Capital HSP DRG Amount · Optional · Decimal number (R) · Min 1 Max 15

MIA-11 · 782 · PPS-Capital DSH DRG Amount · Optional · Decimal number (R) · Min 1 Max 15

MIA-12 · 782 · Old Capital Amount · Optional · Decimal number (R) · Min 1 Max 15

MIA-13 · 782 · PPS-Capital IME amount · Optional · Decimal number (R) · Min 1 Max 15

MIA-14 · 782 · PPS-Operating Hospital Specific DRG Amount · Optional · Decimal number (R) · Min 1 Max 15

MIA-15 · 380 · Cost Report Day Count · Optional · Decimal number (R) · Min 1 Max 15

MIA-16 · 782 · PPS-Operating Federal Specific DRG Amount · Optional · Decimal number (R) · Min 1 Max 15

MIA-17 · 782 · Claim PPS Capital Outlier Amount · Optional · Decimal number (R) · Min 1 Max 15

MIA-18 · 782 · Claim Indirect Teaching Amount · Optional · Decimal number (R) · Min 1 Max 15

MIA-19 · 782 · Nonpayable Professional Component Amount · Optional · Decimal number (R) · Min 1 Max 15

MIA-20 · 127 · Claim Payment Remark Code · Optional · String (AN) · Min 1 Max 50

MIA-21 · 127 · Claim Payment Remark Code · Optional · String (AN) · Min 1 Max 50

MIA-22 · 127 · Claim Payment Remark Code · Optional · String (AN) · Min 1 Max 50

MIA-23 · 127 · Claim Payment Remark Code · Optional · String (AN) · Min 1 Max 50

MIA-24 · 782 · PPS-Capital Exception Amount · Optional · Decimal number (R) · Min 1 Max 15

0350 Detail > Header Number Loop > Claim Payment Information Loop > MOA

MOA Outpatient Adjudication Information

Optional · Max use 1

MOA-01 · 954 · Reimbursement Rate · Optional · Decimal number (R) · Min 1 Max 10

MOA-02 · 782 · Claim HCPCS Payable Amount · Optional · Decimal number (R) · Min 1 Max 15

MOA-03 · 127 · Claim Payment Remark Code · Optional · String (AN) · Min 1 Max 50

MOA-04 · 127 · Claim Payment Remark Code · Optional · String (AN) · Min 1 Max 50

MOA-05 · 127 · Claim Payment Remark Code · Optional · String (AN) · Min 1 Max 50

MOA-06 · 127 · Claim Payment Remark Code · Optional · String (AN) · Min 1 Max 50

MOA-07 · 127 · Claim Payment Remark Code · Optional · String (AN) · Min 1 Max 50

MOA-08 · 782 · Claim ESRD Payment Amount · Optional · Decimal number (R) · Min 1 Max 15

MOA-09 · 782 · Nonpayable Professional Component Amount · Optional · Decimal number (R) · Min 1 Max 15

0400 Detail > Header Number Loop > Claim Payment Information Loop > REF

REF Other Claim Related Identification

Optional · Max use 5

Variants (all may be used)

REFRendering Provider Identification

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 1L: Group or Policy Number
• 1W: Member Identification Number
• 6P: Group Number
• 9A: Repriced Claim Reference Number
• 9C: Adjusted Repriced Claim Reference Number
• 28: Employee Identification Number
• BB: Authorization Number
• CE: Class of Contract Code
• EA: Medical Record Identification Number
• F8: Original Reference Number
• G1: Prior Authorization Number
• G3: Predetermination of Benefits Identification Number
• IG: Insurance Policy Number

REF-02 · 127 · Other Claim Related Identifier · Required · String (AN) · Min 1 Max 50

0400 Detail > Header Number Loop > Claim Payment Information Loop > REF

REF Rendering Provider Identification

Optional · Max use 10

Variants (all may be used)

REFOther Claim Related Identification

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 0B: State License Number
• 1A: Blue Cross Provider Number
• 1B: Blue Shield Provider Number
• 1C: Medicare Provider Number
• 1D: Medicaid Provider Number
• 1G: Provider UPIN Number
• 1H: CHAMPUS Identification Number
• 1J: Facility ID Number
• D3: National Council for Prescription Drug Programs Pharmacy Number
• G2: Provider Commercial Number
• LU: Location Number

REF-02 · 127 · Rendering Provider Secondary Identifier · Required · String (AN) · Min 1 Max 50

0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM

DTM Claim Received Date

Optional · Max use 1

Variants (all may be used)

DTMCoverage Expiration DateDTMStatement From or To Date

DTM-01 · 374 · Date Time Qualifier · Required · Identifier (ID)

• 050: Received

DTM-02 · 373 · Date · Required · Date (DT) · CCYYMMDD format

0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM

DTM Coverage Expiration Date

Optional · Max use 1

Variants (all may be used)

DTMClaim Received DateDTMStatement From or To Date

DTM-01 · 374 · Date Time Qualifier · Required · Identifier (ID)

• 036: Expiration

DTM-02 · 373 · Date · Required · Date (DT) · CCYYMMDD format

0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM

DTM Statement From or To Date

Optional · Max use 2

Variants (all may be used)

DTMClaim Received DateDTMCoverage Expiration Date

DTM-01 · 374 · Date Time Qualifier · Required · Identifier (ID)

• 232: Claim Statement Period Start
• 233: Claim Statement Period End

DTM-02 · 373 · Claim Date · Required · Date (DT) · CCYYMMDD format

0600 Detail > Header Number Loop > Claim Payment Information Loop > PER

PER Claim Contact Information

Optional · Max use 2

If either Communication Number Qualifier (PER-05) or Claim Contact Communications Number (PER-06) is present, then the other is required

If either Communication Number Qualifier (PER-07) or Communication Number Extension (PER-08) is present, then the other is required

PER-01 · 366 · Contact Function Code · Required · Identifier (ID)

• CX: Payers Claim Office

PER-02 · 93 · Claim Contact Name · Optional · String (AN) · Min 1 Max 60

PER-03 · 365 · Communication Number Qualifier · Required · Identifier (ID)

• EM: Electronic Mail
• FX: Facsimile
• TE: Telephone

PER-04 · 364 · Claim Contact Communications Number · Required · String (AN) · Min 1 Max 256

PER-05 · 365 · Communication Number Qualifier · Optional · Identifier (ID)

• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• TE: Telephone

PER-06 · 364 · Claim Contact Communications Number · Optional · String (AN) · Min 1 Max 256

PER-07 · 365 · Communication Number Qualifier · Optional · Identifier (ID)

• EX: Telephone Extension

PER-08 · 364 · Communication Number Extension · Optional · String (AN) · Min 1 Max 256

0620 Detail > Header Number Loop > Claim Payment Information Loop > AMT

AMT Claim Supplemental Information

Optional · Max use 13

AMT-01 · 522 · Amount Qualifier Code · Required · Identifier (ID)

• AU: Coverage Amount
• D8: Discount Amount
• DY: Per Day Limit
• F5: Patient Amount Paid
• I: Interest
• NL: Negative Ledger Balance
• T: Tax
• T2: Total Claim Before Taxes
• ZK: Federal Medicare or Medicaid Payment Mandate - Category 1
• ZL: Federal Medicare or Medicaid Payment Mandate - Category 2
• ZM: Federal Medicare or Medicaid Payment Mandate - Category 3
• ZN: Federal Medicare or Medicaid Payment Mandate - Category 4
• ZO: Federal Medicare or Medicaid Payment Mandate - Category 5

AMT-02 · 782 · Claim Supplemental Information Amount · Required · Decimal number (R) · Min 1 Max 15

0640 Detail > Header Number Loop > Claim Payment Information Loop > QTY

QTY Claim Supplemental Information Quantity

Optional · Max use 14

QTY-01 · 673 · Quantity Qualifier · Required · Identifier (ID)

• CA: Covered - Actual
• CD: Co-insured - Actual
• LA: Life-time Reserve - Actual
• LE: Life-time Reserve - Estimated
• NE: Non-Covered - Estimated
• NR: Not Replaced Blood Units
• OU: Outlier Days
• PS: Prescription
• VS: Visits
• ZK: Federal Medicare or Medicaid Payment Mandate - Category 1
• ZL: Federal Medicare or Medicaid Payment Mandate - Category 2
• ZM: Federal Medicare or Medicaid Payment Mandate - Category 3
• ZN: Federal Medicare or Medicaid Payment Mandate - Category 4
• ZO: Federal Medicare or Medicaid Payment Mandate - Category 5

QTY-02 · 380 · Claim Supplemental Information Quantity · Required · Decimal number (R) · Min 1 Max 15

2110 Service Payment Information Loop Optional Max 999

0700 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > SVC

SVC Service Payment Information

Required · Max use 1

SVC-01 · C003 · Composite Medical Procedure Identifier · Required Max use 1 · To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132).

C003-01 · 235 · Product or Service ID Qualifier · Required · Identifier (ID)

• AD: American Dental Association Codes
• ER: Jurisdiction Specific Procedure and Supply Codes
• HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
• HP: Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
• IV: Home Infusion EDI Coalition (HIEC) Product/Service Code
• N4: National Drug Code in 5-4-2 Format
• N6: National Health Related Item Code in 4-6 Format
• NU: National Uniform Billing Committee (NUBC) UB92 Codes
• UI: U.P.C. Consumer Package Code (1-5-5)
• WK: Advanced Billing Concepts (ABC) Codes

C003-02 · 234 · Adjudicated Procedure Code · Required · String (AN) · Min 1 Max 48

C003-03 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-04 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-05 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-06 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

SVC-02 · 782 · Line Item Charge Amount · Required · Decimal number (R) · Min 1 Max 15

SVC-03 · 782 · Line Item Provider Payment Amount · Required · Decimal number (R) · Min 1 Max 15

SVC-04 · 234 · National Uniform Billing Committee Revenue Code · Optional · String (AN) · Min 1 Max 48

SVC-05 · 380 · Units of Service Paid Count · Optional · Decimal number (R) · Min 1 Max 15

SVC-06 · C003 · Composite Medical Procedure Identifier · Optional Max use 1 · To identify a medical procedure by its standardized codes and applicable modifiers - SVC06 is the original submitted medical procedure. · Usage notes

C003-01 · 235 · Product or Service ID Qualifier · Required · Identifier (ID)

• AD: American Dental Association Codes
• ER: Jurisdiction Specific Procedure and Supply Codes
• HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
• HP: Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
• IV: Home Infusion EDI Coalition (HIEC) Product/Service Code
• N4: National Drug Code in 5-4-2 Format
• NU: National Uniform Billing Committee (NUBC) UB92 Codes
• WK: Advanced Billing Concepts (ABC) Codes

C003-02 · 234 · Procedure Code · Required · String (AN) · Min 1 Max 48

C003-03 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-04 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-05 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-06 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-07 · 352 · Procedure Code Description · Optional · String (AN) · Min 1 Max 80

SVC-07 · 380 · Original Units of Service Count · Optional · Decimal number (R) · Min 1 Max 15

0800 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > DTM

DTM Service Date

Optional · Max use 2

DTM-01 · 374 · Date Time Qualifier · Required · Identifier (ID)

• 150: Service Period Start
• 151: Service Period End
• 472: Service

DTM-02 · 373 · Service Date · Required · Date (DT) · CCYYMMDD format

0900 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > CAS

CAS Service Adjustment

Optional · Max use 99

If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required

If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required

If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required

If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required

If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required

If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required

If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required

If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required

If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required

If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required

If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required

If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required

If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required

If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required

If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required

CAS-01 · 1033 · Claim Adjustment Group Code · Required · Identifier (ID)

• CO: Contractual Obligations
• OA: Other adjustments
• PI: Payor Initiated Reductions
• PR: Patient Responsibility

CAS-02 · 1034 · Adjustment Reason Code · Required · Identifier (ID) · Min 1 Max 5

CAS-03 · 782 · Adjustment Amount · Required · Decimal number (R) · Min 1 Max 15

CAS-04 · 380 · Adjustment Quantity · Optional · Decimal number (R) · Min 1 Max 15

CAS-05 · 1034 · Adjustment Reason Code · Optional · Identifier (ID) · Min 1 Max 5

CAS-06 · 782 · Adjustment Amount · Optional · Decimal number (R) · Min 1 Max 15

CAS-07 · 380 · Adjustment Quantity · Optional · Decimal number (R) · Min 1 Max 15

CAS-08 · 1034 · Adjustment Reason Code · Optional · Identifier (ID) · Min 1 Max 5

CAS-09 · 782 · Adjustment Amount · Optional · Decimal number (R) · Min 1 Max 15

CAS-10 · 380 · Adjustment Quantity · Optional · Decimal number (R) · Min 1 Max 15

CAS-11 · 1034 · Adjustment Reason Code · Optional · Identifier (ID) · Min 1 Max 5

CAS-12 · 782 · Adjustment Amount · Optional · Decimal number (R) · Min 1 Max 15

CAS-13 · 380 · Adjustment Quantity · Optional · Decimal number (R) · Min 1 Max 15

CAS-14 · 1034 · Adjustment Reason Code · Optional · Identifier (ID) · Min 1 Max 5

CAS-15 · 782 · Adjustment Amount · Optional · Decimal number (R) · Min 1 Max 15

CAS-16 · 380 · Adjustment Quantity · Optional · Decimal number (R) · Min 1 Max 15

CAS-17 · 1034 · Adjustment Reason Code · Optional · Identifier (ID) · Min 1 Max 5

CAS-18 · 782 · Adjustment Amount · Optional · Decimal number (R) · Min 1 Max 15

CAS-19 · 380 · Adjustment Quantity · Optional · Decimal number (R) · Min 1 Max 15

1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF

REF HealthCare Policy Identification

Optional · Max use 5

Variants (all may be used)

REFLine Item Control NumberREFRendering Provider InformationREFService Identification

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 0K: Policy Form Identifying Number

REF-02 · 127 · Healthcare Policy Identification · Required · String (AN) · Min 1 Max 50

1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF

REF Line Item Control Number

Optional · Max use 1

Variants (all may be used)

REFHealthCare Policy IdentificationREFRendering Provider InformationREFService Identification

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 6R: Provider Control Number

REF-02 · 127 · Line Item Control Number · Required · String (AN) · Min 1 Max 50

1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF

REF Rendering Provider Information

Optional · Max use 10

Variants (all may be used)

REFHealthCare Policy IdentificationREFLine Item Control NumberREFService Identification

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 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
• TJ: Federal Taxpayer's Identification Number

REF-02 · 127 · Rendering Provider Identifier · Required · String (AN) · Min 1 Max 50

1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF

REF Service Identification

Optional · Max use 8

Variants (all may be used)

REFHealthCare Policy IdentificationREFLine Item Control NumberREFRendering Provider Information

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

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

REF-02 · 127 · Provider Identifier · Required · String (AN) · Min 1 Max 50

1100 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > AMT

AMT Service Supplemental Amount

Optional · Max use 9

AMT-01 · 522 · Amount Qualifier Code · Required · Identifier (ID)

• B6: Allowed - Actual
• KH: Deduction Amount
• T: Tax
• T2: Total Claim Before Taxes
• ZK: Federal Medicare or Medicaid Payment Mandate - Category 1
• ZL: Federal Medicare or Medicaid Payment Mandate - Category 2
• ZM: Federal Medicare or Medicaid Payment Mandate - Category 3
• ZN: Federal Medicare or Medicaid Payment Mandate - Category 4
• ZO: Federal Medicare or Medicaid Payment Mandate - Category 5

AMT-02 · 782 · Service Supplemental Amount · Required · Decimal number (R) · Min 1 Max 15

1200 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > QTY

QTY Service Supplemental Quantity

Optional · Max use 6

QTY-01 · 673 · Quantity Qualifier · Required · Identifier (ID)

• ZK: Federal Medicare or Medicaid Payment Mandate - Category 1
• ZL: Federal Medicare or Medicaid Payment Mandate - Category 2
• ZM: Federal Medicare or Medicaid Payment Mandate - Category 3
• ZN: Federal Medicare or Medicaid Payment Mandate - Category 4
• ZO: Federal Medicare or Medicaid Payment Mandate - Category 5

QTY-02 · 380 · Service Supplemental Quantity Count · Required · Decimal number (R) · Min 1 Max 15

1300 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > LQ

LQ Health Care Remark Codes

Optional · Max use 99

LQ-01 · 1270 · Code List Qualifier Code · Required · Identifier (ID)

• HE: Claim Payment Remark Codes
• RX: National Council for Prescription Drug Programs Reject/Payment Codes

LQ-02 · 1271 · Remark Code · Required · String (AN) · Min 1 Max 30

Summary

0100 Summary > PLB

PLB Provider Adjustment

Optional · Max use >1

If either Adjustment Identifier (PLB-05) or Provider Adjustment Amount (PLB-06) is present, then the other is required

If either Adjustment Identifier (PLB-07) or Provider Adjustment Amount (PLB-08) is present, then the other is required

If either Adjustment Identifier (PLB-09) or Provider Adjustment Amount (PLB-10) is present, then the other is required

If either Adjustment Identifier (PLB-11) or Provider Adjustment Amount (PLB-12) is present, then the other is required

If either Adjustment Identifier (PLB-13) or Provider Adjustment Amount (PLB-14) is present, then the other is required

PLB-01 · 127 · Provider Identifier · Required · String (AN) · Min 1 Max 50

PLB-02 · 373 · Fiscal Period Date · Required · Date (DT) · CCYYMMDD format

PLB-03 · C042 · Adjustment Identifier · Required Max use 1 · To provide the category and identifying reference information for an adjustment - PLB03 is the adjustment information as defined by the payer.

C042-01 · 426 · Adjustment Reason Code · Required · Identifier (ID)

• 50: Late Charge
• 51: Interest Penalty Charge
• 72: Authorized Return
• 90: Early Payment Allowance
• AH: Origination Fee
• AM: Applied to Borrower's Account
• AP: Acceleration of Benefits
• B2: Rebate
• B3: Recovery Allowance
• BD: Bad Debt Adjustment
• BN: Bonus
• C5: Temporary Allowance
• CR: Capitation Interest
• CS: Adjustment
• CT: Capitation Payment
• CV: Capital Passthru
• CW: Certified Registered Nurse Anesthetist Passthru
• DM: Direct Medical Education Passthru
• E3: Withholding
• FB: Forwarding Balance
• FC: Fund Allocation
• GO: Graduate Medical Education Passthru
• HM: Hemophilia Clotting Factor Supplement
• IP: Incentive Premium Payment
• IR: Internal Revenue Service Withholding
• IS: Interim Settlement
• J1: Nonreimbursable
• L3: Penalty
• L6: Interest Owed
• LE: Levy
• LS: Lump Sum
• OA: Organ Acquisition Passthru
• OB: Offset for Affiliated Providers
• PI: Periodic Interim Payment
• PL: Payment Final
• RA: Retro-activity Adjustment
• RE: Return on Equity
• SL: Student Loan Repayment
• TL: Third Party Liability
• WO: Overpayment Recovery
• WU: Unspecified Recovery

C042-02 · 127 · Provider Adjustment Identifier · Optional · String (AN) · Min 1 Max 50

PLB-04 · 782 · Provider Adjustment Amount · Required · Decimal number (R) · Min 1 Max 15

PLB-05 · C042 · Adjustment Identifier · Optional Max use 1 · To provide the category and identifying reference information for an adjustment - PLB05 is the adjustment information as defined by the payer. · Usage notes

C042-01 · 426 · Adjustment Reason Code · Required · Identifier (ID) · Min 2 Max 2

C042-02 · 127 · Provider Adjustment Identifier · Optional · String (AN) · Min 1 Max 50

PLB-06 · 782 · Provider Adjustment Amount · Optional · Decimal number (R) · Min 1 Max 15

PLB-07 · C042 · Adjustment Identifier · Optional Max use 1 · To provide the category and identifying reference information for an adjustment - PLB07 is adjustment information as defined by the payer. · Usage notes

C042-01 · 426 · Adjustment Reason Code · Required · Identifier (ID) · Min 2 Max 2

C042-02 · 127 · Provider Adjustment Identifier · Optional · String (AN) · Min 1 Max 50

PLB-08 · 782 · Provider Adjustment Amount · Optional · Decimal number (R) · Min 1 Max 15

PLB-09 · C042 · Adjustment Identifier · Optional Max use 1 · To provide the category and identifying reference information for an adjustment - PLB09 is adjustment information as defined by the payer. · Usage notes

C042-01 · 426 · Adjustment Reason Code · Required · Identifier (ID) · Min 2 Max 2

C042-02 · 127 · Provider Adjustment Identifier · Optional · String (AN) · Min 1 Max 50

PLB-10 · 782 · Provider Adjustment Amount · Optional · Decimal number (R) · Min 1 Max 15

PLB-11 · C042 · Adjustment Identifier · Optional Max use 1 · To provide the category and identifying reference information for an adjustment - PLB11 is adjustment information as defined by the payer. · Usage notes

C042-01 · 426 · Adjustment Reason Code · Required · Identifier (ID) · Min 2 Max 2

C042-02 · 127 · Provider Adjustment Identifier · Optional · String (AN) · Min 1 Max 50

PLB-12 · 782 · Provider Adjustment Amount · Optional · Decimal number (R) · Min 1 Max 15

PLB-13 · C042 · Adjustment Identifier · Optional Max use 1 · To provide the category and identifying reference information for an adjustment - PLB13 is adjustment information as defined by the payer. · Usage notes

C042-01 · 426 · Adjustment Reason Code · Required · Identifier (ID) · Min 2 Max 2

C042-02 · 127 · Provider Adjustment Identifier · Optional · String (AN) · Min 1 Max 50

PLB-14 · 782 · Provider Adjustment Amount · Optional · Decimal number (R) · Min 1 Max 15

0200 Summary > SE

SE Transaction Set Trailer

Required · Max use 1

SE-01 · 96 · Transaction Segment Count · Required · Numeric (N0) · Min 1 Max 10

SE-02 · 329 · Transaction Set Control Number · Required · Numeric (N) · Min 4 Max 9

GE Functional Group Trailer

Required · Max use 1

GE-01 · 97 · Number of Transaction Sets Included · Required · Numeric (N0) · Min 1 Max 6

GE-02 · 28 · Group Control Number · Required · Numeric (N0) · Min 1 Max 9

IEA Interchange Control Trailer

Required · Max use 1

IEA-01 · I16 · Number of Included Functional Groups · Required · Numeric (N0) · Min 1 Max 5

IEA-02 · I12 · Interchange Control Number · Required · Numeric (N0) · Min 9 Max 9

EDI Samples

Example 1: Dollars and Data Sent Separately

ISA*00*          *00*          *ZZ*ABCPAYER       *ZZ*ABCPAYER       *190827*0212*^*00501*191511902*0*P*>~
GS*HP*ABCD*ABCD*20190827*12345678*012345678*X*005010X221A1~
ST*835*112233~
BPR*I*1100*C*ACH*CCP*01*888999777*DA*24681012*1935665544**01*111333555*DA*144444*20190316~
TRN*1*71700666555*1935665544~
DTM*405*20190314~
N1*PR*RUSHMORE LIFE~
N3*10 SOUTH AVENUET~
N4*RAPID CITY*SD*55111~
PER*BL*JOHN WAYNE*TE*8005551212*EX*123~
N1*PE*ACME MEDICAL CENTER*XX*5544667733~
REF*0B*777667755~
LX*1~
CLP*5554555444*1*800*500*300*12*94060555410000*11*1~
NM1*QC*1*BUDD*WILLIAM****MI*33344555510~
AMT*AU*800~
SVC*HC>99211*800*500~
DTM*472*20190301~
CAS*PR*1*300~
AMT*B6*800~
CLP*8765432112*1*1200*600*600*12*9407779923000*11*1~
NM1*QC*1*SETTLE*SUSAN****MI*44455666610~
AMT*AU*1200~
SVC*HC>93555*1200*600~
DTM*472*20190310~
CAS*PR*1*600~
AMT*B6*1200~
SE*26*112233~
GE*1*012345678~
IEA*1*191511902~

Example 2: Multiple Claims Single Check

ISA*00*          *00*          *ZZ*ABCPAYER       *ZZ*ABCPAYER       *190827*0212*^*00501*191511902*0*P*>~
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*35681~
BPR*I*810.8*C*CHK************20190331~
TRN*1*12345*1512345678~
REF*EV*XYZ CLEARINGHOUSE~
N1*PR*DENTAL OF ABC~
N3*225 MAIN STREET~
N4*CENTERVILLE*PA*17111~
PER*BL*JANE DOE*TE*9005555555~
N1*PE*BAN DDS LLC*XX*9999947036~
REF*0B*212121212~
LX*1~
CLP*7722337*1*226*132**12*119932404007801*11*1~
NM1*QC*1*DOE*SANDY****MI*SJD11112~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*132~
SVC*AD>D0120*46*25~
DTM*472*20190324~
CAS*CO*45*21~
AMT*B6*25~
SVC*AD>D0220*25*14~
DTM*472*20190324~
CAS*CO*45*11~
AMT*B6*14~
SVC*AD>D0230*22*10~
DTM*472*20190324~
CAS*CO*45*12~
AMT*B6*10~
SVC*AD>D0274*60*34~
DTM*472*20190324~
CAS*CO*45*26~
AMT*B6*34~
SVC*AD>D1110*73*49~
DTM*472*20190324~
CAS*CO*45*24~
AMT*B6*49~
CLP*7722337*1*119*74**12*119932404007801*11*1~
NM1*QC*1*DOE*SALLY****MI*SJD11111~
NM1*IL*1*DOE*JOHN****MI*SJD11111~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*74~
SVC*AD>D0120*46*25~
DTM*472*20190324~
CAS*CO*45*21~
AMT*B6*25~
SVC*AD>D1110*73*49~
DTM*472*20190324~
CAS*CO*45*24~
AMT*B6*49~
CLP*7722337*1*226*108*24*12*119932404007801*11*1~
NM1*QC*1*SMITH*SALLY****MI*SJD11113~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*132~
SVC*AD>D0120*46*25~
DTM*472*20190324~
CAS*CO*45*21~
AMT*B6*25~
SVC*AD>D0220*25*0~
DTM*472*20190324~
CAS*PR*3*14~
CAS*CO*45*11~
AMT*B6*14~
SVC*AD>D0230*22*0~
DTM*472*20190324~
CAS*PR*3*10~
CAS*CO*45*12~
AMT*B6*10~
SVC*AD>D0274*60*34~
DTM*472*20190324~
CAS*CO*45*26~
AMT*B6*34~
SVC*AD>D1110*73*49~
DTM*472*20190324~
CAS*CO*45*24~
AMT*B6*49~
CLP*7722337*1*1145*14*902*12*119932404007801*11*1~
NM1*QC*1*SMITH*SAM****MI*SJD11116~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*14~
SVC*AD>D0220*25*14~
DTM*472*20190324~
CAS*CO*45*11~
AMT*B6*14~
SVC*AD>D2790*940*0~
DTM*472*20190324~
CAS*PR*3*756~
CAS*CO*45*184~
SVC*AD>D2950*180*0~
DTM*472*20190324~
CAS*PR*3*146~
CAS*CO*45*34~
CLP*7722337*1*348*16.8*44.2*12*119932404007801*11*1~
NM1*QC*1*JONES*SAM****MI*SJD11122~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*28~
SVC*AD>D4342*125*0~
DTM*472*20190313~
CAS*CO*45*125~
SVC*AD>D4381*43*0~
DTM*472*20190313~
CAS*PR*3*33~
CAS*CO*45*10~
SVC*AD>D2950*180*16.8~
DTM*472*20190313~
CAS*PR*3*11.2~
CAS*CO*45*152~
AMT*B6*28~
CLP*7722337*1*226*132**12*119932404007801*11*1~
NM1*QC*1*JONES*SALLY****MI*SJD11133~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*132~
SVC*AD>D0120*46*25~
DTM*472*20190321~
CAS*CO*45*21~
AMT*B6*25~
SVC*AD>D0220*25*14~
DTM*472*20190321~
CAS*CO*45*11~
AMT*B6*14~
SVC*AD>D0230*22*10~
DTM*472*20190321~
CAS*CO*45*12~
AMT*B6*10~
SVC*AD>D0274*60*34~
DTM*472*20190321~
CAS*CO*45*26~
AMT*B6*34~
SVC*AD>D1110*73*49~
DTM*472*20190321~
CAS*CO*45*24~
AMT*B6*49~
CLP*7722337*1*179*108**12*119932404007801*11*1~
NM1*QC*1*DOE*SAM****MI*SJD99999~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*108~
SVC*AD>D0120*46*25~
DTM*472*20190324~
CAS*CO*45*21~
AMT*B6*25~
SVC*AD>D0274*60*34~
DTM*472*20190324~
CAS*CO*45*26~
AMT*B6*34~
SVC*AD>D1110*73*49~
DTM*472*20190324~
CAS*CO*45*24~
AMT*B6*49~
CLP*7722337*1*129*82**12*119932404007801*11*1~
NM1*QC*1*DOE*SUE****MI*SJD88888~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*82~
SVC*AD>D0120*46*25~
DTM*472*20190324~
CAS*CO*45*21~
AMT*B6*25~
SVC*AD>D1120*54*37~
DTM*472*20190324~
CAS*CO*45*17~
AMT*B6*37~
SVC*AD>D1208*29*20~
DTM*472*20190324~
CAS*CO*45*9~
AMT*B6*20~
CLP*7722337*1*221*144**12*119932404007801*11*1~
NM1*QC*1*DOE*DONNA****MI*SJD77777~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*144~
SVC*AD>D0120*46*25~
DTM*472*20190324~
CAS*CO*45*21~
AMT*B6*25~
SVC*AD>D0330*92*62~
DTM*472*20190324~
CAS*CO*45*30~
AMT*B6*62~
SVC*AD>D1120*54*37~
DTM*472*20190324~
CAS*CO*45*17~
AMT*B6*37~
SVC*AD>D1208*29*20~
DTM*472*20190324~
CAS*CO*45*9~
AMT*B6*20~
SE*183*35681~
GE*1*12345678~
IEA*1*191511902~

Example 3: Claim Specific Negotiated Discount

ISA*00*          *00*          *ZZ*ABCPAYER       *ZZ*ABCPAYER       *190827*0212*^*00501*191511902*0*P*>~
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*35681~
BPR*I*132*C*CHK************20190331~
TRN*1*12345*1512345678~
REF*EV*CLEARINGHOUSE~
N1*PR*DELTA DENTAL OF ABC~
N3*225 MAIN STREET~
N4*CENTERVILLE*PA*17111~
PER*BL*JANE DOE*TE*9005555555~
N1*PE*BAN DDS LLC*XV*999994703~
LX*1~
CLP*7722337*1*226*132**12*119932404007801~
NM1*QC*1*DOE*SALLY****MI*SJD11111~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*132~
SVC*AD>D0120*46*25~
DTM*472*20190324~
CAS*CO*131*21~
AMT*B6*25~
SVC*AD>D0220*25*14~
DTM*472*20190324~
CAS*CO*131*11~
AMT*B6*14~
SVC*AD>D0230*22*10~
DTM*472*20190324~
CAS*CO*131*12~
AMT*B6*10~
SVC*AD>D0274*60*34~
DTM*472*20190324~
CAS*CO*131*26~
AMT*B6*34~
SVC*AD>D1110*73*49~
DTM*472*20190324~
CAS*CO*131*24~
AMT*B6*49~
SE*35*35681~
GE*1*12345678~
IEA*1*191511902~

Example 4: Claim Adjustment Reason Code 45

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

Example 5a: Line Service Tax impacting payment only

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

Example 5b: Line Service Bonuses impacting payment only

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

Example 5c: Line Service Penalty impacting payment only

ISA*00*          *00*          *ZZ*ABCPAYER       *ZZ*ABCPAYER       *190827*0212*^*00501*191511902*0*P*>~
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*10060875~
BPR*I*8.00*C*CHK************20190816~
TRN*1*CK NUMBER 1*1234567890~
REF*EV*FAC~
DTM*405*20190827~
N1*PR*ANY PLAN USA~
N3*1 WALK THIS WAY~
N4*ANYCITY*OH*45209~
PER*CX**TE*8661112222~
PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
PER*IC**UR*WWW.ANYPAYER.COM~
N1*PE*PROVIDER*XX*1123454567~
N3*2255 ANY ROAD~
N4*ANY CITY*CA*12211~
REF*0B*123456789~
LX*1~
CLP*PCN*1*25*8*10*12*CLAIMNUMB*11*1~
NM1*QC*1*LAST*FIRST*J***MI*123456789~
NM1*82*1******XX*1447481825~
MOA***N25~
REF*1L*102345~
REF*EA*065789~
DTM*050*20170113~
AMT*AU*25~
SVC*HC>99214*25*8~
DTM*472*20170109~
CAS*CO*45*5**B4*2~
CAS*PR*3*10~
REF*6R*123~
AMT*B6*20~
SE*31*10060875~
GE*1*12345678~
IEA*1*191511902~

Example 6: Not Covered/Not Authorized Inpatient Facility claim days

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

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

ISA*00*          *00*          *ZZ*ABCPAYER       *ZZ*ABCPAYER       *190827*0212*^*00501*191511902*0*P*|~
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*10060875~
BPR*I*120.03*C*CHK************20190816~
TRN*1*CK NUMBER 1*1234567890~
REF*EV*FAC~
DTM*405*20190827~
N1*PR*ANY PLAN USA~
N3*1 WALK THIS WAY~
N4*ANYCITY*OH*45209~
PER*CX**TE*8661112222~
PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
PER*IC**UR*WWW.ANYPAYER.COM~
N1*PE*PROVIDER*XX*1123454567~
N3*2255 ANY ROAD~
N4*ANY CITY*CA*12211~
REF*0B*123456789~
LX*1~
CLP*04777796TLC777122*1*155*120.03**13*8838888212*11*1~
NM1*QC*1*MASTERS*MARVIN*L***MI*80444444403~
NM1*IL*1*CABLE*MABEL****MI*80444444403~
NM1*74*1*MASTERS*MARVIN****C*80444444401~
NM1*82*1*SHELTON MD*BLAKE****XX*1666666666~
REF*1L*28~
REF*CE*HSOAP-LAOA~
DTM*232*20191114~
DTM*233*20181114~
DTM*050*20181119~
AMT*AU*155~
SVC*HC|99393*155*120.03**1~
DTM*472*20181114~
CAS*CO*45*34.97~
REF*LU*11~
REF*6R*22261822~
AMT*B6*120.03~
SE*34*10060875~
GE*1*12345678~
IEA*1*191511902~

Example 8b: Claim submitted with incorrect subscriber name and ID

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

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

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