X12 835 Health Care Claim Payment/Advice (X221A1)

Reassociation Trace Number

Functional Group Header

Transaction Set Header

Financial Information

Foreign Currency Information

Receiver Identification

Version Identification

Payer Identification Loop

Payer City, State, ZIP Code

Additional Payer Identification

Payer Business Contact Information

Payer Technical Contact Information

Payee Identification Loop

Payee City, State, ZIP Code

Payee Additional Identification

Remittance Delivery Method

Provider Summary Information

Provider Supplemental Summary Information

Claim Payment Information Loop

Optional

CLP

0100

Claim Payment Information

Corrected Patient/Insured Name

Corrected Priority Payer Name

Crossover Carrier Name

Other Subscriber Name

Service Provider Name

Inpatient Adjudication Information

Outpatient Adjudication Information

Other Claim Related Identification

Rendering Provider Identification

Coverage Expiration Date

Statement From or To Date

Claim Contact Information

Claim Supplemental Information

Claim Supplemental Information Quantity

Max use 14

Optional

Service Payment Information Loop

SVC

0700

Service Payment Information

HealthCare Policy Identification

Line Item Control Number

Rendering Provider Information

Service Identification

Service Supplemental Amount

Service Supplemental Quantity

Max use 6

Optional

1300

Health Care Remark Codes

Transaction Set Trailer

Functional Group Trailer

Interchange Control Trailer

IEA

REFVersion Identification

ISA

Interchange Control Header

RequiredMax use 1

—

Example

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 10Max 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 10Max 10

—

ISA-05

I05

Interchange ID Qualifier

Required

Identifier (ID)

Min 2Max 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 15Max 15

—

ISA-07

I05

Interchange ID Qualifier

Required

Identifier (ID)

Min 2Max 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 15Max 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 1Max 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 9Max 9

—

ISA-14

I13

Acknowledgment Requested

Required

Identifier (ID)

Min 1Max 1

—

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

ISA-15

I14

Interchange Usage Indicator

Required

Identifier (ID)

Min 1Max 1

—

I: Information
P: Production Data
T: Test Data

ISA-16

I15

Component Element Separator

Required

String (AN)

Min 1Max 1

—

>: Component Element Separator

Functional Group Header

RequiredMax use 1

—

Example

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 2Max 15

—

GS-03

124

Application Receiver's Code

Required

String (AN)

Min 2Max 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

Group Control Number

Required

Numeric (N0)

Min 1Max 9

—

GS-07

455

Responsible Agency Code

Required

Identifier (ID)

Min 1Max 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

Transaction Set Header

RequiredMax use 1

—

Example

ST-01

143

Transaction Set Identifier Code

Required

Identifier (ID)

—

Usage notes

—

835: Health Care Claim Payment/Advice

ST-02

329

Transaction Set Control Number

Required

Numeric (N)

Min 4Max 9

—

Usage notes

—

BPR

0200

Heading > BPR

Financial Information

RequiredMax use 1

—

Usage notes

—

Example

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

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

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

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

BPR-01

305

Transaction Handling Code

Required

Identifier (ID)

—

H: Notification Only
—
I: Remittance Information Only
—

BPR-02

782

Total Actual Provider Payment Amount

Required

Decimal number (R)

Min 1Max 15

—

Usage notes

—

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)
—
CHK: Check
—

BPR-05

812

Payment Format Code

Optional

Identifier (ID)

—

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

BPR-06

506

Depository Financial Institution (DFI) Identification Number Qualifier

Optional

Identifier (ID)

—

Usage notes

—

01: ABA Transit Routing Number Including Check Digits (9 digits)
—

BPR-07

507

Sender DFI Identifier

Optional

String (AN)

Min 3Max 12

—

Usage notes

—

BPR-08

569

Account Number Qualifier

Optional

Identifier (ID)

—

Usage notes

—

DA: Demand Deposit

BPR-09

508

Sender Bank Account Number

Optional

String (AN)

Min 1Max 35

—

Usage notes

—

BPR-10

509

Payer Identifier

Optional

String (AN)

—

1391572880

BPR-11

510

Originating Company Supplemental Code

Optional

String (AN)

Min 9Max 9

—

Usage notes

—

BPR-12

506

Depository Financial Institution (DFI) Identification Number Qualifier

Optional

Identifier (ID)

—

Usage notes

—

01: ABA Transit Routing Number Including Check Digits (9 digits)
—

BPR-13

507

Receiver or Provider Bank ID Number

Optional

String (AN)

Min 3Max 12

—

Usage notes

—

BPR-14

569

Account Number Qualifier

Optional

Identifier (ID)

—

Usage notes

—

DA: Demand Deposit

BPR-15

508

Receiver or Provider Account Number

Optional

String (AN)

Min 1Max 35

—

Usage notes

—

BPR-16

373

Check Issue or EFT Effective Date

Required

Date (DT)

CCYYMMDD format

—

Usage notes

—

TRN

0400

Heading > TRN

Reassociation Trace Number

RequiredMax use 1

—

Usage notes

—

Example

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 1Max 50

—

Usage notes

—

TRN-03

509

Payer Identifier

Required

String (AN)

—

Usage notes

—

1391572880

TRN-04

127

Originating Company Supplemental Code

Optional

String (AN)

Min 1Max 50

—

Usage notes

—

CUR

0500

Heading > CUR

Foreign Currency Information

OptionalMax use 1

—

Usage notes

—

Example

CUR-01

Entity Identifier Code

Required

Identifier (ID)

—

PR: Payer

CUR-02

100

Currency Code

Required

Identifier (ID)

Min 3Max 3

—

Usage notes

—

REF

0600

Heading > REF

Receiver Identification

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

EV: Receiver Identification Number

REFReceiver Identification

127

Receiver Identifier

Required

String (AN)

Min 1Max 50

—

REF

0600

Heading > REF

Version Identification

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

F2: Version Code - Local

127

Version Identification Code

Required

String (AN)

Min 1Max 50

—

DTM

0700

Heading > DTM

Production Date

OptionalMax use 1

—

Usage notes

—

Example

374

Date Time Qualifier

Required

Identifier (ID)

—

405: Production

Payee Identification Loop

373

Production Date

Required

Date (DT)

CCYYMMDD format

—

Usage notes

—

1000A Payer Identification Loop

RequiredMax 1

Variants (all may be used)

0800

Heading > Payer Identification Loop > N1

Payer Identification

RequiredMax use 1

—

Usage notes

—

Example

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

N1-01

Entity Identifier Code

Required

Identifier (ID)

—

PR: Payer

N1-02

Payer Name

Required

String (AN)

—

ADVOCARE
FAMILY HEALTH CENTER
MEDICAID
SECURITY HEALTH PLAN
TPA

N1-03

Identification Code Qualifier

Optional

Identifier (ID)

—

XV: Centers for Medicare and Medicaid Services PlanID
—

N1-04

Payer Identifier

Optional

String (AN)

Min 2Max 80

—

1000

Heading > Payer Identification Loop > N3

Payer Address

RequiredMax use 1

—

Example

N3-01

166

Payer Address Line

Required

String (AN)

Min 1Max 55

—

N3-02

166

Payer Address Line

Optional

String (AN)

Min 1Max 55

—

1100

Heading > Payer Identification Loop > N4

Payer City, State, ZIP Code

RequiredMax use 1

—

Example

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

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

N4-01

Payer City Name

Required

String (AN)

Min 2Max 30

—

N4-02

156

Payer State Code

Optional

Identifier (ID)

Min 2Max 2

—

N4-03

116

Payer Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

N4-04

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

N4-07

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

REF

1200

Heading > Payer Identification Loop > REF

Additional Payer Identification

OptionalMax use 4

—

Usage notes

—

Example

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
—

PERPayer Technical Contact Information PERPayer WEB Site

127

Additional Payer Identifier

Required

String (AN)

Min 1Max 50

—

PER

1300

Heading > Payer Identification Loop > PER

Payer Business Contact Information

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

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

366

Contact Function Code

Required

Identifier (ID)

—

CX: Payers Claim Office

PER-02

Payer Contact Name

Optional

String (AN)

—

Usage notes

—

PROVIDER RELATIONS

365

Communication Number Qualifier

Optional

Identifier (ID)

—

TE: Telephone

PERPayer Business Contact Information PERPayer WEB Site

364

Payer Contact Communication Number

Optional

String (AN)

—

8005481224

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 1Max 256

—

PER-07

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EX: Telephone Extension

PER-08

364

Payer Contact Communication Number

Optional

String (AN)

Min 1Max 256

—

PER

1300

Heading > Payer Identification Loop > PER

Payer Technical Contact Information

RequiredMax use >1

—

Usage notes

—

Example

Variants (all may be used)

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

366

Contact Function Code

Required

Identifier (ID)

—

BL: Technical Department

PER-02

Payer Technical Contact Name

Optional

String (AN)

Min 1Max 60

—

Usage notes

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

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

PERPayer Business Contact Information PERPayer Technical Contact Information

364

Payer Contact Communication Number

Optional

String (AN)

Min 1Max 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 1Max 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 1Max 256

—

PER

1300

Heading > Payer Identification Loop > PER

Payer WEB Site

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

366

Contact Function Code

Required

Identifier (ID)

—

IC: Information Contact

365

Communication Number Qualifier

Required

Identifier (ID)

—

UR: Uniform Resource Locator (URL)

Payer Identification Loop

364

Communication Number

Required

String (AN)

Min 1Max 256

—

Usage notes

—

1000A Payer Identification Loop end

1000B Payee Identification Loop

RequiredMax 1

Variants (all may be used)

0800

Heading > Payee Identification Loop > N1

Payee Identification

RequiredMax use 1

—

Usage notes

—

Example

N1-01

Entity Identifier Code

Required

Identifier (ID)

—

PE: Payee

N1-02

Payee Name

Required

String (AN)

Min 1Max 60

—

N1-03

Identification Code Qualifier

Required

Identifier (ID)

—

FI: Federal Taxpayer's Identification Number
—
XX: Centers for Medicare and Medicaid Services National Provider Identifier
—

N1-04

Payee Identification Code

Required

String (AN)

Min 2Max 80

—

1000

Heading > Payee Identification Loop > N3

Payee Address

OptionalMax use 1

—

Usage notes

—

Example

N3-01

166

Payee Address Line

Required

String (AN)

Min 1Max 55

—

N3-02

166

Payee Address Line

Optional

String (AN)

Min 1Max 55

—

1100

Heading > Payee Identification Loop > N4

Payee City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

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

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

N4-01

Payee City Name

Required

String (AN)

Min 2Max 30

—

N4-02

156

Payee State Code

Optional

Identifier (ID)

Min 2Max 2

—

N4-03

116

Payee Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

N4-04

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

N4-07

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

REF

1200

Heading > Payee Identification Loop > REF

Payee Additional Identification

OptionalMax use >1

—

Usage notes

—

Example

128

Reference Identification Qualifier

Required

Identifier (ID)

—

PQ: Payee Identification
TJ: Federal Taxpayer's Identification Number
—

NM1Corrected Priority Payer Name NM1Crossover Carrier Name NM1Insured Name NM1Other Subscriber Name NM1Patient Name NM1Service Provider Name

127

Additional Payee Identifier

Required

String (AN)

Min 1Max 50

—

RDM

1400

Heading > Payee Identification Loop > RDM

Remittance Delivery Method

OptionalMax use 1

—

Usage notes

—

Example

RDM-01

756

Report Transmission Code

Required

Identifier (ID)

—

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

RDM-02

Name

Optional

String (AN)

Min 1Max 60

—

Usage notes

—

RDM-03

364

Communication Number

Optional

String (AN)

Min 1Max 256

—

Usage notes

—

1000B Payee Identification Loop end

Heading end

Detail

2000 Header Number Loop

OptionalMax >1

0030

Detail > Header Number Loop > LX

Header Number

RequiredMax use 1

—

Usage notes

—

Example

LX-01

554

Assigned Number

Required

Numeric (N0)

Min 1Max 6

—

TS3

0050

Detail > Header Number Loop > TS3

Provider Summary Information

OptionalMax use 1

—

Usage notes

—

Example

TS3-01

127

Provider Identifier

Required

String (AN)

Min 1Max 50

—

Usage notes

—

TS3-02

1331

Facility Type Code

Required

String (AN)

Min 1Max 2

—

Usage notes

—

TS3-03

373

Fiscal Period Date

Required

Date (DT)

CCYYMMDD format

—

Usage notes

—

TS3-04

380

Total Claim Count

Required

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS3-05

782

Total Claim Charge Amount

Required

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS3-13

782

Total MSP Payer Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS3-15

782

Total Non-Lab Charge Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS3-17

782

Total HCPCS Reported Charge Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS3-18

782

Total HCPCS Payable Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS3-20

782

Total Professional Component Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS3-21

782

Total MSP Patient Liability Met Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS3-22

782

Total Patient Reimbursement Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS3-23

380

Total PIP Claim Count

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS3-24

782

Total PIP Adjustment Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS2

0070

Detail > Header Number Loop > TS2

Provider Supplemental Summary Information

OptionalMax use 1

—

Usage notes

—

Example

TS2-01

782

Total DRG Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS2-02

782

Total Federal Specific Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS2-03

782

Total Hospital Specific Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS2-04

782

Total Disproportionate Share Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS2-05

782

Total Capital Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS2-06

782

Total Indirect Medical Education Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS2-07

380

Total Outlier Day Count

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS2-08

782

Total Day Outlier Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS2-09

782

Total Cost Outlier Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS2-10

380

Average DRG Length of Stay

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS2-11

380

Total Discharge Count

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS2-12

380

Total Cost Report Day Count

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS2-13

380

Total Covered Day Count

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS2-14

380

Total Noncovered Day Count

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS2-15

782

Total MSP Pass-Through Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS2-16

380

Average DRG weight

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS2-17

782

Total PPS Capital FSP DRG Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS2-18

782

Total PPS Capital HSP DRG Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

TS2-19

782

Total PPS DSH DRG Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

2100 Claim Payment Information Loop

RequiredMax >1

CLP

0100

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

Claim Payment Information

RequiredMax use 1

—

Usage notes

—

Example

CLP-01

1028

Patient Control Number

Required

String (AN)

Min 1Max 38

—

Usage notes

—

CLP-02

1029

Claim Status Code

Required

Identifier (ID)

—

Usage notes

—

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 1Max 15

—

Usage notes

—

CLP-04

782

Claim Payment Amount

Required

Decimal number (R)

Min 1Max 15

—

Usage notes

—

CLP-05

782

Patient Responsibility Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

CLP-06

1032

Claim Filing Indicator Code

Required

Identifier (ID)

—

Usage notes

—

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 1Max 50

—

Usage notes

—

CLP-08

1331

Facility Type Code

Optional

String (AN)

Min 1Max 2

—

Usage notes

—

CLP-09

1325

Claim Frequency Code

Optional

Identifier (ID)

Min 1Max 1

—

Usage notes

—

CLP-11

1354

Diagnosis Related Group (DRG) Code

Optional

Identifier (ID)

Min 1Max 4

—

CLP-12

380

Diagnosis Related Group (DRG) Weight

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

CLP-13

954

Discharge Fraction

Optional

Decimal number (R)

Min 1Max 10

—

Usage notes

—

CAS

0200

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

Claim Adjustment

OptionalMax use 99

—

Usage notes

—

Example

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CAS-01

1033

Claim Adjustment Group Code

Required

Identifier (ID)

—

Usage notes

—

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

CAS-02

1034

Adjustment Reason Code

Required

Identifier (ID)

Min 1Max 5

—

Usage notes

—

CAS-03

782

Adjustment Amount

Required

Decimal number (R)

Min 1Max 15

—

Usage notes

—

CAS-04

380

Adjustment Quantity

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

CAS-05

1034

Adjustment Reason Code

Optional

Identifier (ID)

Min 1Max 5

—

CAS-06

782

Adjustment Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

CAS-07

380

Adjustment Quantity

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

CAS-08

1034

Adjustment Reason Code

Optional

Identifier (ID)

Min 1Max 5

—

CAS-09

782

Adjustment Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

CAS-10

380

Adjustment Quantity

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

CAS-11

1034

Adjustment Reason Code

Optional

Identifier (ID)

Min 1Max 5

—

CAS-12

782

Adjustment Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

CAS-13

380

Adjustment Quantity

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

CAS-14

1034

Adjustment Reason Code

Optional

Identifier (ID)

Min 1Max 5

—

CAS-15

782

Adjustment Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

CAS-16

380

Adjustment Quantity

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

CAS-17

1034

Adjustment Reason Code

Optional

Identifier (ID)

Min 1Max 5

—

CAS-18

782

Adjustment Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

CAS-19

380

Adjustment Quantity

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

NM1

0300

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

Corrected Patient/Insured Name

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

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

Entity Identifier Code

Required

Identifier (ID)

—

74: Corrected Insured

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person
2: Non-Person Entity

1035

Corrected Patient or Insured Last Name

Optional

String (AN)

Min 1Max 60

—

1036

Corrected Patient or Insured First Name

Optional

String (AN)

Min 1Max 35

—

1037

Corrected Patient or Insured Middle Name

Optional

String (AN)

Min 1Max 25

—

Usage notes

—

1039

Corrected Patient or Insured Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Optional

Identifier (ID)

—

C: Insured's Changed Unique Identification Number

NM1Corrected Patient/Insured Name NM1Crossover Carrier Name NM1Insured Name NM1Other Subscriber Name NM1Patient Name NM1Service Provider Name

Corrected Insured Identification Indicator

Optional

String (AN)

Min 2Max 80

—

NM1

0300

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

Corrected Priority Payer Name

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

Entity Identifier Code

Required

Identifier (ID)

—

PR: Payer

1065

Entity Type Qualifier

Required

Identifier (ID)

—

2: Non-Person Entity

1035

Corrected Priority Payer Name

Required

String (AN)

Min 1Max 60

—

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
—

NM1Corrected Patient/Insured Name NM1Corrected Priority Payer Name NM1Insured Name NM1Other Subscriber Name NM1Patient Name NM1Service Provider Name

Corrected Priority Payer Identification Number

Required

String (AN)

Min 2Max 80

—

NM1

0300

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

Crossover Carrier Name

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

Entity Identifier Code

Required

Identifier (ID)

—

TT: Transfer To

1065

Entity Type Qualifier

Required

Identifier (ID)

—

2: Non-Person Entity

1035

Crossover Carrier Name

Required

String (AN)

Min 1Max 60

—

Usage notes

—

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
—

NM1Corrected Patient/Insured Name NM1Corrected Priority Payer Name NM1Crossover Carrier Name NM1Other Subscriber Name NM1Patient Name NM1Service Provider Name

Crossover Carrier Identifier

Required

String (AN)

Min 2Max 80

—

NM1

0300

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

Insured Name

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

Entity Identifier Code

Required

Identifier (ID)

—

IL: Insured or Subscriber

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person
2: Non-Person Entity

1035

Subscriber Last Name

Optional

String (AN)

Min 1Max 60

—

1036

Subscriber First Name

Optional

String (AN)

Min 1Max 35

—

1037

Subscriber Middle Name or Initial

Optional

String (AN)

Min 1Max 25

—

Usage notes

—

1039

Subscriber Name Suffix

Optional

String (AN)

Min 1Max 10

—

Usage notes

—

Identification Code Qualifier

Required

Identifier (ID)

—

MI: Member Identification Number
—

NM1Corrected Patient/Insured Name NM1Corrected Priority Payer Name NM1Crossover Carrier Name NM1Insured Name NM1Patient Name NM1Service Provider Name

Subscriber Identifier

Required

String (AN)

Min 2Max 80

—

Usage notes

—

NM1

0300

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

Other Subscriber Name

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

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

Entity Identifier Code

Required

Identifier (ID)

—

GB: Other Insured

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person
2: Non-Person Entity

1035

Other Subscriber Last Name

Optional

String (AN)

Min 1Max 60

—

Usage notes

—

1036

Other Subscriber First Name

Optional

String (AN)

Min 1Max 35

—

1037

Other Subscriber Middle Name or Initial

Optional

String (AN)

Min 1Max 25

—

Usage notes

—

1039

Other Subscriber Name Suffix

Optional

String (AN)

Min 1Max 10

—

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
—

NM1Corrected Patient/Insured Name NM1Corrected Priority Payer Name NM1Crossover Carrier Name NM1Insured Name NM1Other Subscriber Name NM1Service Provider Name

Other Subscriber Identifier

Optional

String (AN)

Min 2Max 80

—

Usage notes

—

NM1

0300

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

Patient Name

RequiredMax use 1

—

Usage notes

—

Example

Variants (all may be used)

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

Entity Identifier Code

Required

Identifier (ID)

—

QC: Patient

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person

1035

Patient Last Name

Optional

String (AN)

Min 1Max 60

—

1036

Patient First Name

Optional

String (AN)

Min 1Max 35

—

1037

Patient Middle Name or Initial

Optional

String (AN)

Min 1Max 25

—

Usage notes

—

1039

Patient Name Suffix

Optional

String (AN)

Min 1Max 10

—

Usage notes

—

Identification Code Qualifier

Optional

Identifier (ID)

—

MI: Member Identification Number

NM1Corrected Patient/Insured Name NM1Corrected Priority Payer Name NM1Crossover Carrier Name NM1Insured Name NM1Other Subscriber Name NM1Patient Name

Patient Identifier

Optional

String (AN)

Min 2Max 80

—

Usage notes

—

NM1

0300

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

Service Provider Name

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

Entity Identifier Code

Required

Identifier (ID)

—

82: Rendering Provider

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person
2: Non-Person Entity

1035

Rendering Provider Last or Organization Name

Optional

String (AN)

Min 1Max 60

—

1036

Rendering Provider First Name

Optional

String (AN)

Min 1Max 35

—

1037

Rendering Provider Middle Name or Initial

Optional

String (AN)

Min 1Max 25

—

Usage notes

—

1039

Rendering Provider Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Required

Identifier (ID)

—

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

REFRendering Provider Identification

Rendering Provider Identifier

Required

String (AN)

Min 2Max 80

—

MIA

0330

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

Inpatient Adjudication Information

OptionalMax use 1

—

Usage notes

—

Example

MIA-01

380

Covered Days or Visits Count

Required

Decimal number (R)

Min 1Max 15

—

Usage notes

—

MIA-02

782

PPS Operating Outlier Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

MIA-03

380

Lifetime Psychiatric Days Count

Optional

Decimal number (R)

Min 1Max 15

—

MIA-04

782

Claim DRG Amount

Optional

Decimal number (R)

Min 1Max 15

—

MIA-05

127

Claim Payment Remark Code

Optional

String (AN)

Min 1Max 50

—

MIA-06

782

Claim Disproportionate Share Amount

Optional

Decimal number (R)

Min 1Max 15

—

MIA-07

782

Claim MSP Pass-through Amount

Optional

Decimal number (R)

Min 1Max 15

—

MIA-08

782

Claim PPS Capital Amount

Optional

Decimal number (R)

Min 1Max 15

—

MIA-09

782

PPS-Capital FSP DRG Amount

Optional

Decimal number (R)

Min 1Max 15

—

MIA-10

782

PPS-Capital HSP DRG Amount

Optional

Decimal number (R)

Min 1Max 15

—

MIA-11

782

PPS-Capital DSH DRG Amount

Optional

Decimal number (R)

Min 1Max 15

—

MIA-12

782

Old Capital Amount

Optional

Decimal number (R)

Min 1Max 15

—

MIA-13

782

PPS-Capital IME amount

Optional

Decimal number (R)

Min 1Max 15

—

MIA-14

782

PPS-Operating Hospital Specific DRG Amount

Optional

Decimal number (R)

Min 1Max 15

—

MIA-15

380

Cost Report Day Count

Optional

Decimal number (R)

Min 1Max 15

—

MIA-16

782

PPS-Operating Federal Specific DRG Amount

Optional

Decimal number (R)

Min 1Max 15

—

MIA-17

782

Claim PPS Capital Outlier Amount

Optional

Decimal number (R)

Min 1Max 15

—

MIA-18

782

Claim Indirect Teaching Amount

Optional

Decimal number (R)

Min 1Max 15

—

MIA-19

782

Nonpayable Professional Component Amount

Optional

Decimal number (R)

Min 1Max 15

—

MIA-20

127

Claim Payment Remark Code

Optional

String (AN)

Min 1Max 50

—

MIA-21

127

Claim Payment Remark Code

Optional

String (AN)

Min 1Max 50

—

MIA-22

127

Claim Payment Remark Code

Optional

String (AN)

Min 1Max 50

—

MIA-23

127

Claim Payment Remark Code

Optional

String (AN)

Min 1Max 50

—

MIA-24

782

PPS-Capital Exception Amount

Optional

Decimal number (R)

Min 1Max 15

—

MOA

0350

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

Outpatient Adjudication Information

OptionalMax use 1

—

Usage notes

—

Example

MOA-01

954

Reimbursement Rate

Optional

Decimal number (R)

Min 1Max 10

—

MOA-02

782

Claim HCPCS Payable Amount

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

MOA-03

127

Claim Payment Remark Code

Optional

String (AN)

Min 1Max 50

—

MOA-04

127

Claim Payment Remark Code

Optional

String (AN)

Min 1Max 50

—

MOA-05

127

Claim Payment Remark Code

Optional

String (AN)

Min 1Max 50

—

MOA-06

127

Claim Payment Remark Code

Optional

String (AN)

Min 1Max 50

—

MOA-07

127

Claim Payment Remark Code

Optional

String (AN)

Min 1Max 50

—

MOA-08

782

Claim ESRD Payment Amount

Optional

Decimal number (R)

Min 1Max 15

—

MOA-09

782

Nonpayable Professional Component Amount

Optional

Decimal number (R)

Min 1Max 15

—

REF

0400

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

Other Claim Related Identification

OptionalMax use 5

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

1L: Group or Policy Number
—
1W: Member Identification Number
F8: Original Reference Number
—
IG: Insurance Policy Number
—

REFOther Claim Related Identification

127

Other Claim Related Identifier

Required

String (AN)

Min 1Max 50

—

Usage notes

—

REF

0400

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

Rendering Provider Identification

OptionalMax use 10

—

Usage notes

—

Example

Variants (all may be used)

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

DTMCoverage Expiration Date DTMStatement From or To Date

127

Rendering Provider Secondary Identifier

Required

String (AN)

Min 1Max 50

—

DTM

0500

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

Claim Received Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

050: Received

DTMClaim Received Date DTMStatement From or To Date

373

Date

Required

Date (DT)

CCYYMMDD format

—

Usage notes

—

DTM

0500

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

Coverage Expiration Date

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

036: Expiration

DTMClaim Received Date DTMCoverage Expiration Date

373

Date

Required

Date (DT)

CCYYMMDD format

—

Usage notes

—

DTM

0500

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

Statement From or To Date

OptionalMax use 2

—

Usage notes

—

Example

Variants (all may be used)

374

Date Time Qualifier

Required

Identifier (ID)

—

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

373

Claim Date

Required

Date (DT)

CCYYMMDD format

—

PER

0600

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

Claim Contact Information

OptionalMax use 2

—

Usage notes

—

Example

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

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

366

Contact Function Code

Required

Identifier (ID)

—

CX: Payers Claim Office

PER-02

Claim Contact Name

Optional

String (AN)

Min 1Max 60

—

365

Communication Number Qualifier

Required

Identifier (ID)

—

EM: Electronic Mail
FX: Facsimile
TE: Telephone

364

Claim Contact Communications Number

Required

String (AN)

Min 1Max 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 1Max 256

—

PER-07

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EX: Telephone Extension

PER-08

364

Communication Number Extension

Optional

String (AN)

Min 1Max 256

—

AMT

0620

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

Claim Supplemental Information

OptionalMax use 13

—

Usage notes

—

Example

AMT-01

522

Amount Qualifier Code

Required

Identifier (ID)

—

AU: Coverage Amount
—
I: Interest
—

AMT-02

782

Claim Supplemental Information Amount

Required

Decimal number (R)

Min 1Max 15

—

Usage notes

—

QTY

0640

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

Claim Supplemental Information Quantity

OptionalMax use 14

—

Usage notes

—

Example

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 1Max 15

—

2110 Service Payment Information Loop

OptionalMax 999

SVC

0700

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

Service Payment Information

RequiredMax use 1

—

Usage notes

—

Example

SVC-01

C003

Composite Medical Procedure Identifier

RequiredMax 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)

—

Usage notes

—

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 1Max 48

—

Usage notes

—

C003-03

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

C003-04

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

C003-05

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

C003-06

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

SVC-02

782

Line Item Charge Amount

Required

Decimal number (R)

Min 1Max 15

—

Usage notes

—

SVC-03

782

Line Item Provider Payment Amount

Required

Decimal number (R)

Min 1Max 15

—

Usage notes

—

SVC-04

234

National Uniform Billing Committee Revenue Code

Optional

String (AN)

Min 1Max 48

—

Usage notes

—

SVC-05

380

Units of Service Paid Count

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

SVC-06

C003

Composite Medical Procedure Identifier

OptionalMax 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)

—

Usage notes

—

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 1Max 48

—

C003-03

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

C003-04

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

C003-05

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

C003-06

1339

Procedure Modifier

Optional

String (AN)

Min 2Max 2

—

C003-07

352

Procedure Code Description

Optional

String (AN)

Min 1Max 80

—

SVC-07

380

Original Units of Service Count

Optional

Decimal number (R)

Min 1Max 15

—

DTM

0800

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

Service Date

OptionalMax use 2

—

Usage notes

—

Example

374

Date Time Qualifier

Required

Identifier (ID)

—

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