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Stedi maintains this guide based on public documentation from CGS Medicare. Contact CGS Medicare for official EDI specifications. To report any errors in this guide, please contact us. X12 835 Health Care Claim Payment/Advice (X221A1) X12 Release 5010 Revised November 17, 2023 Go to Stedi Network This X12 Transaction S... | CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99) GS-06 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsib... | CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
the transfer instructions Usage notes 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 13/125 Use this code to further identify the payer by division or regi... | CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
name N1-03 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). N1-04 67 Payer Identifier Min 2 Max... | CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
this implementation guide, do not send. This is a direct link to the policy location of the un-secure website. Example PER*IC**UR*XXXXX~ Variants (all may be used) PER Payer Business Contact Information PER Payer Technical Contact Information Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required ... | CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
mandatory elements (TS302 through TS305) must be valid with appropriate data, as defined by the TS3 segment. Only Medicare Part A uses data elements TS313, TS315, TS317, TS318 and TS320 through TS324. Each monetary amount element is for that provider for this facility type code for loop 2000. Required for Medicare Part... | CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
system (PPS) capital, federal-specific portion, diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. TS2-18 782 Total PPS Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS218 is the total prospective payment system (PPS) capital, hospital-specific portion, diagnosis-related... | CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
for a particular service within the claim being paid Usage notes Payers must use this CAS segment to report claim level adjustments that cause the amount paid to differ from the amount originally charged. See 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional infor... | CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 57/125 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Corre... | CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Patient First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Patient Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Pa... | CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as ... | CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
- Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 79/125 PER 0600 Detail > Header Number Loop > Claim Payment Information Loop > PER Claim Contact Information To identify a person or office to whom administrative communications should... | CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
in C003-02 and C003-08. SVC-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC02 is the submitted service charge. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-p... | CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 90/125 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required I... | CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 97/125 REF 1000 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > REF Service Identification To specify identifying information Usage notes Required... | CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
from the provider for overpayments generated by payments from other payers. This code differs from the provider refund adjustment identified with code 72. This adjustment must always be offset by some other PLB adjustment referring to the original refund request or reason. For balancing purposes, the amount related to ... | CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
adjustment amount for the preceding adjustment reason. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 108/125 Summary end SE 0200 Summary > SE Transaction ... | CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
GAINWELL TECHNOLOGIES Louisiana Medicaid 837 Health Care Claim-Institutional Companion Guide Based on ASC X12N Version 005010X223A2 CORE v5010 Master Companion Guide Template Issued January 2018 Version 1.6 Revised 1/14/2025 837 Institutional Companion Guide i Revision History See Appendix C. Usage Information Document... | 837_Institutional_Companion_Guide.pdf |
All Trading Partners are required to submit test EDI transactions before being authorized to submit production EDI transactions. The Usage Indicator, element 15 of the Interchange Control Header (ISA) of any X12 file, indicates if a file is test or production. Authorization is granted on a per transaction basis. For ex... | 837_Institutional_Companion_Guide.pdf |
the line level (SVC – Service Payment Information). There is a limit of 20,000 CLM segments in a claims file. NOTE: National Provider Identification Numbers are to be submitted in all 837I transactions. Atypical providers who have not registered an NPI with Louisiana Medicaid may continue to submit their legacy Medicai... | 837_Institutional_Companion_Guide.pdf |
multiple LA Medicaid provider numbers, a tie-breaker such as taxonomy may be required for unique identification of the Medicaid provider ID. Use the same Taxonomy code that was registered with Louisiana Medicaid for the Billing Provider. 84 2010AA NM1 Billing Provider Name If the Billing provider is an atypical provide... | 837_Institutional_Companion_Guide.pdf |
81 for non-cov days Code 82 for co-insur days Code 83 for Lifetime reserve days Element Separator * 1 837 Institutional Companion Guide 26 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments HI01-05 Value Code Amount <Quantity or Dollar Value> 1/8 Enter number or dollar value. Values greater than 999 are inva... | 837_Institutional_Companion_Guide.pdf |
for LA Medicaid is seven whole numbers and three decimal places. Element Separator * 1 453 CTP05-01 Unit or Basis of Measurement Code F2, GE, ME, ML, UN 2/2 F2 = International Unit GR = Gram ME = Milligram ML = Milliliter UN = Unit Segment End ~ 1 2420C NM1 Rendering Provider Name If present, the rendering provider ide... | 837_Institutional_Companion_Guide.pdf |
submit electronic transactions as a remedy to the covering plan, and to mitigate provider abrasion created by having the biller’s previous payment recovered and requesting them to rebill elsewhere. Medicaid Subrogation is a process recognized by CMS and ANSI allowing reimbursement between Payers. Subrogation will allow... | 837_Institutional_Companion_Guide.pdf |
HIPAA Transaction Standard Companion Guide Healthcare Claim Payment/Advice ASC X12N 835 Version 005010X221A1 for State of Idaho MMIS Date of Publication: 02/29/2024 Document Number: TL419 Version: 11.0 Idaho MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page ii Revision History Ve... | CAQH 5010 835 Companion Guide (1).pdf |
and other X12 Companion Guides. For information on how to use the portal once registered as a trading partner, click the User Guides link under Reference Material. For any questions or to begin testing, contact the Gainwell Technologies EDI Helpdesk at 1 (866) 686-4272 option 2, or e-mail us at idedisupport@gainwelltec... | CAQH 5010 835 Companion Guide (1).pdf |
Agreements A trading partner agreement is comprised of the completion of the trading partner registration activities and the approval to submit or receive specific transactions. Please refer to Section 2, sub-section Trading Partner Registration, for information on how to register as a trading partner and be authorized... | CAQH 5010 835 Companion Guide (1).pdf |
The dollar amount included in the payment for the claim Element Separator * 1 CLP05 Monetary Amount 1/18 Co-Pay Amount Element Separator * 1 126 CLP06 Claim Filing Indicator Code MC - Medicaid 1/2 Code Identifying the type of claim Element Separator * 1 127 CLP07 Reference Identification 1/50 Claim Internal Control Num... | CAQH 5010 835 Companion Guide (1).pdf |
MMIS Companion Guide – 835 Health Care Claim Payment/Advice Last Updated: 02/29/2024 Page 19 of 22 Page # Loop ID Reference Name Codes Length Notes / Comments Note: A second CAS segment for the Claim Detail will be mapped if more than six (6) detail EOB codes are passed. 204 2110 REF Service Identification REF 3 Elemen... | CAQH 5010 835 Companion Guide (1).pdf |
Centers for Medicare & Medicaid Services (CMS) Standard Companion Guide Health Care Claim Institutional (837I) Based on ASC X12N TR3, Version 005010X223A2 Companion Guide Version Number: 8.0, June 2023 CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. ii Disclosure Statement The C... | 837I_compguide.pdf |
in this section. • Testing and Certification Requirements: This section includes detailed transaction testing information as well as certification requirements needed to complete transaction testing with Medicare. • Connectivity/Communications: This section includes information on Medicare’s transmission procedures as ... | 837I_compguide.pdf |
submitted to CGS containing at least 25 claims with a T in the ISA15. Description of delivery and interpretation of results. Once the test file is submitted, verify the file received an accepted 999 and 277CA. Once an error free 277CA populates the EDI helpdesk should be contacted to move the submitter ID into producti... | 837I_compguide.pdf |
Used Dec Value Hex Value Data Element Separator * 42 2A Repetition Separator ^ 94 5E CMS 837I Version 005010X223A2 Companion Guide © 2022 Copyright, CGS Administrators, LLC. 13 Delimiter Character Used Dec Value Hex Value Component Element Separator > 62 3E Segment Terminator ~ 126 7E Inbound Data Element Detail and Ex... | 837I_compguide.pdf |
Medicare is Secondary or Tertiary payer, Total Submitted Charges (CLM02) must equal the sum of all 2320 & 2430 CAS amounts and the 2320 AMT02 (AMT01= “D”). 147 2300 CLM20 Delay Reason Code - 2 Data submitted in CLM20 will not be used for processing. 148 2300 DTP03 Admission Date - - Must not be a future date. 149 2300 ... | 837I_compguide.pdf |
HP 2 Must be “HC” or “HP”. 479 2430 SVD05 Quantity - 15 Must be greater than zero. Must be less than or equal to “999,999.9”. Must be 0 or 1 decimal position. 479 2430 SVD06 Bundled Line Number - 6 Must be an integer (no decimals). 486 2430 DTP03 Line Check/Remit Date - 35 Must not be a future date. 10.4.18 Transaction... | 837I_compguide.pdf |
Health Care Claim 837 Companion Guide Version 1.5 Refers to the following Technical Report Type 3 Guides: • ASC X12N 837 Institutional (version 005010X223A2) • ASC X12N 837 Professional (version 005010X222A1) • ASC X12N 837 Dental (version 005010X224A2) © Blue Cross Blue Shield of Massachusetts, February 2024 837 BLUE ... | MPC_092315-4N___837_Companion_Guide.pdf |
Technology Drive Hingham, MA 02043 Mail Stop 03-02 Attention: Scott Howard Director, Provider Operations & EDI Services You may email both the Trading Partner Enrollment Form and Secure File Transfer Account Request Form to EDISupport@bcbsma.com. Please use “Enrollment and Security Forms” in the subject line of the ema... | MPC_092315-4N___837_Companion_Guide.pdf |
claims data Avoid the use of special characters in the claim data itself. Punctuation—comma (,), period (.), colon (:), semicolon (;), and hyphen (-)—should be avoided in the claims data (e.g. names, addresses, identifiers). Delimiters Delimiters are characters used to separate data and component elements or to termina... | MPC_092315-4N___837_Companion_Guide.pdf |
is known to be impacted by the provider taxonomy code In general, provider taxonomy code is not required for Blue Cross claims. However, if you have been instructed by Blue Cross to submit your provider taxonomy code in order to crosswalk your NPI, it is required. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION G... | MPC_092315-4N___837_Companion_Guide.pdf |
state, and ZIP Code of the facility where the services were rendered 270 N401 / 19 Address information Required when reporting a service facility location in NM1 Use: City of the service facility location Refer to Appendix B Facility Code Requirements for 837P claims for Blue Cross 270 N402 / 156 Address information ... | MPC_092315-4N___837_Companion_Guide.pdf |
the subscriber is the same person as the patient. If the subscriber is not the same person as the patient, do not use this element. Loop 2010BA Subscriber Name 015 NM1 Individual or organization name To supply the full name of an individual or organizational entity 015 NM109 / 67 Identification code Situational, but re... | MPC_092315-4N___837_Companion_Guide.pdf |
number of the billing provider Use: The billing provider’s 9-digit tax ID number (without dashes) Loop 2000B Subscriber Information 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE © Blue Cross Blue Shield of Massachusetts, February 2024 57 837D implementation guide data Payer specific data Position Segmen... | MPC_092315-4N___837_Companion_Guide.pdf |
segment name 2010BB | REF Billing provider secondary identification 2310B | REF (Claim Level) Rendering provider secondary identification 2420A | REF (Service Line Level) Rendering provider secondary identification Facility code requirements for 837P and 837I claims for Blue Cross The service facility location loop—231... | MPC_092315-4N___837_Companion_Guide.pdf |
CPT or HCPCS code xxx” • On claims originally denied for exceeding the timely filing limit. Refer to our timely filing appeals guidelines in the Blue Book • If the original claim is processed and the late charges exceed the filing limit as outlined in the Blue Book • To change the type of bill on either a professional ... | MPC_092315-4N___837_Companion_Guide.pdf |
when a different from the service line rendering provider X Remittance date There are two options for the remittance date. It can either be on the claim level (2330B) or on the line level (2430). We typically see inpatient institutional remittance date on the claim level (2330B) and outpatient/professional on the line ... | MPC_092315-4N___837_Companion_Guide.pdf |
Stedi maintains this guide based on public documentation from Anthem. Contact Anthem for official EDI specifications. To report any errors in this guide, please contact us. X12 835 Health Care Claim Payment/Advice (X221A1) X12 Release 5010 Revised March 1, 2024 Go to Stedi Network This X12 Transaction Set contains the ... | Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
= hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99) GS-06 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible... | Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
Deposit BPR-09 508 Sender Bank Account Number Min 1 Max 35 String (AN) Optional Account number assigned BPR09 is the account of the company originating the payment. This account may be debited or credited depending on the type of payment order. Usage notes 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X... | Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 21/127 1000A Payer Identification Loop Max 1 Required Variants (all may be used) Payee Identification Loop N1 0800 Heading > Payer Identi... | Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 28/127 PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electro... | Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
service level segments. This number is intended to be unique within each transaction. Example LX*00~ Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi E... | Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
note 2. TS2-16 380 Average DRG weight Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 44/127 Numeric value of quantity TS216 is... | Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
Group (DRG) Code Min 1 Max 4 Identifier (ID) Optional Code indicating a patient's diagnosis group based on a patient's illness, diseases, and medical problems CLP-12 380 Diagnosis Related Group (DRG) Weight Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CLP12 is the diagnosis-related group (DRG) wei... | Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Corrected Patient or Insured Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Corrected Patient or Insured Firs... | Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
Optional Individual last name or organizational name Usage notes At least one of NM103 or NM109 must be present. NM1-04 1036 Other Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1/29/25, 8:52 PM Anthem 8... | Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Cap... | Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
Number 1G Provider UPIN Number 1H CHAMPUS Identification Number 1J Facility ID Number D3 National Council for Prescription Drug Programs Pharmacy Number G2 Provider Commercial Number LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined ... | Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
> Claim Payment Information Loop > QTY Claim Supplemental Information Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send one QTY for each non-zero value. Do not report any zero values. Required when the value of a ... | Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
covered under HIPAA. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes WK Advanced Billing Concepts (ABC) Codes This qualifier can only be used in transactions covere under HIPAA by parties registered in the pilot project and their trading partners. C003-02 234 Procedure Code... | Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
CAS02. CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04... | Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
Use this monetary amount for the service charge before taxes. This is only used when there is an applicable tax amount on this service. ZK Federal Medicare or Medicaid Payment Mandate - Category 1 ZL Federal Medicare or Medicaid Payment Mandate - Category 2 ZM Federal Medicare or Medicaid Payment Mandate - Category 3 Z... | Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
Forward Processing, for further information. FC Fund Allocation This is capitation specific. See 1.10.2.10, Capitation and Related Payments or Adjustments, for additional information. The specific fund must be identified in PLB03-2. GO Graduate Medical Education Passthru HM Hemophilia Clotting Factor Supplement IP Ince... | Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
Anthem 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/anthem/health-care-claim-paymentadvice-x221a1/01HQWPEZE89AKHP7SZ7YAE893C 111/127 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE*000*000~ Max ... | Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
Stedi maintains this guide based on public documentation from X12 HIPAA. Contact X12 HIPAA for official EDI specifications. To report any errors in this guide, please contact us. X12 835 Health Care Claim Payment/Advice (X221A1) X12 Release 5010 Revised May 3, 2024 Go to Stedi Network This X12 Transaction Set contains ... | X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99) GS-06 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated ... | X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
notes Use this code to identify the type of account in BPR09. DA Demand Deposit BPR-09 508 Sender Bank Account Number Min 1 Max 35 String (AN) Optional Account number assigned BPR09 is the account of the company originating the payment. This account may be debited or credited depending on the type of payment order. Usa... | X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
calendar year Usage notes Report the end date for the adjudication production cycle for claims included in this 835. 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 2... | X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
for the payer entity. PER-04 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/hea... | X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
specified in RDM01 (i.e. fax phone number and mail address). Usage notes 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 36/128 1000B Payee Identification Loop end He... | X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
notes See TR3 note 2. TS2-11 380 Total Discharge Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS211 is the total number of discharges. Usage notes This is the discharge count produced by PPS PRICER SOFTWARE. See TR3 note 2. TS2-12 380 Total Cost Report Day Count Min 1 Max 15 Decimal number (... | X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
notes 1/29/25, 8:51 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 49/128 Use this number for the payer's internal control number. This number must apply to the entire claim. CLP-... | X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
CAS19 is the units of service being adjusted. Usage notes See CAS04. 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/hipaa/health-care-claim-paymentadvice-x221a1/01GRYB6DS30MGXWBPFZCM3695E 55/128 NM1 0300 Detail > Header Number Loop > Cla... | X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
62/128 Individual middle name or initial Usage notes If this data element is used and contains only one character, it represents the middle initial. NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Cod... | X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
(PPS) Operating Outlier amount. Usage notes See TR3 note 4. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements. MIA-03 380 Lifetime Psychiatric Days Count Min 1 Ma... | X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
value from the original claim payment, one iteration of this REF segment using this qualifier is REQUIRED to identify the original claim CLP07 value in REF02. See section 1.10.2.8, Reversals and Corrections, for additional information. G1 Prior Authorization Number Use this qualifier when reporting the number received ... | X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
Code Identifier (ID) Required Code to qualify amount AU Coverage Amount Use this monetary amount to report the total covered charges. This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan. This excludes charges considered not covered (... | X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
380 Units of Service Paid Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC05 is the paid units of service. Usage notes If not present, the value is assumed to be one. SVC-06 C003 Composite Medical Procedure Identifier Max use 1 Optional 1/29/25, 8:52 PM X12 HIPAA 835 Health Care Claim Paymen... | X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
reported in this order.) CO Contractual Obligations Use this code when a joint payer/payee agreement or a regulatory requirement has resulted in an adjustment. OA Other adjustments Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13. PI ... | X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
Medicare LMRP's.( Local Medicare Review policies) and NCD (National Coverage Determinations). This policy segment must not be used to provide a proprietary explanation code or reason for adjustment. Supply the Healthcare policy identifier in REF02 as provided by the payer's published Healthcare policy code list. This p... | X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
the amount in PLB04. A positive value represents a withholding. A negative value represents a payment. B2 Rebate This adjustment code applies when a provider has remitted an overpayment to a health plan in excess of the amount requested by the health plan. The amount accepted by the health plan is reported using code 7... | X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB12 is the adjustment amount. Usage notes This is the adjustment amount for the preceding adjustment reason. PLB-13 C042 Adjustment Identifier To provide the category and identifying reference information for an adjustment - PLB13 is adjustment information as d... | X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation. Example 8c: Claim submitted with for subscriber missing the Middle initial ISA*00* *00* *ZZ*ABCPAYER *ZZ*ABCPAYER *190827*0212*^*00... | X12 HIPAA 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
Stedi maintains this guide based on public documentation from Health Partner Plans. Contact Health Partner Plans for official EDI specifications. To report any errors in this guide, please contact us. X12 835 Health Care Claim Payment/Advice (X221A1) X12 Release 5010 Revised February 22, 2024 Go to Stedi Network This X... | Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed 005010X221A1 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.st... | Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
Code identifying the country subdivision Usage notes 1/29/25, 8:52 PM Health Partner Plans 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/health-partner-plans/health-care-claim-paymentadvice-x221a1/01H16H5SPA8ZB874WBF4EWR25K 16/82 Use the country subdivision codes... | Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
be provided at the sender's discretion, but cannot be required by the receiver. Situational (when needed to inform Receiver) Example N4*XXXXXX*XX*XXXXXXXX*XXX~ 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... | Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
Decimal number (R) Required Monetary amount CLP03 is the amount of submitted charges this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. Use this monetary amount for the submitted charges for this claim. The amount can be positive, zero or negative. An example of a ... | Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
been identified in another NM1 segment AND the name or ID of the other subscriber is known. If not required by this implementation guide, do not send. Example NM1*GB*2*X*XX*XXXX**XXXXXX*FI*XXXXX~ Variants (all may be used) NM1 Patient Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Ot... | Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. ... | Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
dates for individual service lines. Required when claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. For retail ph... | Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
Identifier (ID) Required Code to qualify amount B6 Allowed - Actual Allowed amount is the amount the payer deems payable prior to considering patient responsibility. KH Deduction Amount Late Filing Reduction T Tax T2 Total Claim Before Taxes Use this monetary amount for the service charge before taxes. This is only use... | Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
adjustment must be identified in PLB03-2. OA Organ Acquisition Passthru OB Offset for Affiliated Providers Identification of the affiliated providers must be made on PLB03-2. PI Periodic Interim Payment This is the periodic interim lump sum payments and reductions (PIP). The payments are made to a provider at the begin... | Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
CLP*04777796TLC777122*1*155*120.03**HM*8838888212*11*1~ NM1*QC*1*MASTERS*MARVIN*L***MI*80444444403~ NM1*82*1*SHELTON MD*BLAKE****XX*1666666666~ DTM*050*20181119~ AMT*D8*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*27*10060875~ GE*1*12345678~ IEA*1*191... | Health Partner Plans 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
HIPAA Transaction Standard Companion Guide 835 – Health Care Claim Payment Advice Refers to the Implementation Guides Based on X12 version 005010 Errata Companion Guide Version Number: 1.1 February 2024 Disclaimer Statement The Health Insurance Portability and Accountability Act (HIPAA), sections 160 and 162, require t... | HIPAA SummaCare 835 Companion Guide 5010.pdf |
Accompanies Remittance Advice D- Make payment only Financial Information BPR03 Credit / Debit Flag Code C C - Credit Financial Information BPR04 Payment Method Code ACH, CHK ACH - Automated Clearing House CHK - Check Financial Information BPR05 Payment Format Code CCP CCP - Cash Concentration / Disbursement plus Addend... | HIPAA SummaCare 835 Companion Guide 5010.pdf |
SummaCare website http://www.summacare.com/Provider/ResourcesAndSelfServices.aspx. 5. As a provider can I receive my 835 directly from SummaCare? Yes, SummaCare can set up a direct File Transfer Protocol (FTP) secure internet connection for the provider to directly pick up their 835 from SummaCare. SUMMACARE COMPANION ... | HIPAA SummaCare 835 Companion Guide 5010.pdf |
Stedi maintains this guide based on public documentation from Security Health. Contact Security Health for official EDI specifications. To report any errors in this guide, please contact us. X12 835 Health Care Claim Payment/Advice (X221A1) X12 Release 5010 Revised November 20, 2023 Go to Stedi Network This X12 Transac... | Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99) GS-06 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated ... | Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
Min 3 Max 12 String (AN) Optional Depository Financial Institution (DFI) identification number Usage notes Use this number for the identifying number of the financial institution receiving the transaction from the applicable network. Routing Number of Receiver or Provider Bank BPR-14 569 Account Number Qualifier Identi... | Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1/29/25, 8:52 PM Security Health 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/security-health/health-care-claim-paymentadvice-x221a1/01H25KKVA6Q3PW0CJ2PES5TEHE 22/124 ... | Security Health 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf |
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