835 Health Care Claim Payment/Advice (008020X322)

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

405

Production

Required

373

Date

X 1

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

SEGMENT SYNTAX: R020305

INDUSTRY NAME: Production Date

Report the end date for the adjudication production cycle for claims included in this 835.

Not Used

337

Time

X 1

4/8

Not Used

623

Time Code

O 1

Not Used

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1251

Date Time Period

X 1

1/35

DTM*036 - CARD EXPIRATION DATE

X12 Name:

Date/Time Reference

X12 Purpose:

To specify pertinent dates and times

X12 Syntax:

R020305
At least one of DTM02, DTM03 or DTM05 is required.
C0403
If DTM04 is present, then DTM03 is required.
P0506
If either DTM05 or DTM06 is present, then the other is required.

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when payment is made by a card that has an expiration date and the 835 is used as the payment notification. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

TR3 Example:

DTM✱036✱20221231~

DTM

✱

✱

✱

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

036

Expiration

Use when the date in DTM02 reflects the expiration date of the payment card.

Required

373

Date

X 1

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

SEGMENT SYNTAX: R020305

INDUSTRY NAME: Card Expiration Date

When the expiration date on the payment card is not in the CCYYMMDD format, but only includes the month and year (MMYY), default the days (DD) to the last day of the month specified, and default the century to the current century (CC).

Not Used

337

Time

X 1

4/8

Not Used

623

Time Code

O 1

Not Used

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1251

Date Time Period

X 1

1/35

N1*PR - PAYER IDENTIFICATION

X12 Name:

Party Identification

X12 Purpose:

To identify a party by type of organization, name, and code

X12 Syntax:

R0203
At least one of N102 or N103 is required.
P0304
If either N103 or N104 is present, then the other is required.
C0703
If N107 is present, then N103 is required.

X12 Set Notes:

COMMENT: The N1 loop allows for name/address information for the payer and payee which would be utilized to address remittance(s) for delivery.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Use this N1 loop to provide the name/address information for the payer.
The payer's secondary identifying reference number is provided in the 1000A REF Additional Payer Identification, if necessary.

TR3 Example:

N1✱PR✱INSURANCE COMPANY OF TIMBUKTU✱XV✱8888888888~

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Payer

Required

Name

X 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Payer Name

This element reflects the name of the Health Plan. In situations where an organization is self-insured, this field could contain the name of the organization's third-party administrator that is recognized by the provider and to which the provider submits its claims. The name reflected here (1000A N102) is the same name on the payment mechanism (i.e., EFT, check, etc.) for accurate reassociation.

Situational

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: R0203, P0304, C0703

SITUATIONAL RULE: Required when N104 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Standard Unique Health Plan Identifier (HPID)

Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

CODE SOURCE: 540: Health Plan Identifier (HPID)

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

COMMENT: This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party.

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when reporting Health Plan Identifier (HPID) or Other Entity Identifier (OEID).If not required by this implementation guide, do not send.

INDUSTRY NAME: Payer Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

C076

Composite Identification Codes

O 1

N3 - PAYER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N3✱201 PARK AVENUE✱SUITE 300~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Payer Address Line

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when a second address line is needed. If not required by this implementation guide, do not send.

INDUSTRY NAME: Payer Address Line

N4 - PAYER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
E0308
Only one of N403 or N408 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Postal Code
Formatted

X 1

3/20

Required

City Name

O 1

2/30

Free-form text for city name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

INDUSTRY NAME: Payer City Name

Situational

156

State or Province Code

X 1

Code specifying the Standard State/Province as defined by appropriate government agency

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Payer State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

Code specifying international postal zone code excluding punctuation and blanks (zip code for United States)

COMMENT: N403 contains the postal code in an unstructured format. N408 contains the postal code in a structured format. When a postal code data field is used, the parties shall agree as to which data element (N403 or N408) shall be used in the transaction set.

SEGMENT SYNTAX: E0308

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada, or when a postal code exists for the country in N404. If not required by this implementation guide, do not send.

INDUSTRY NAME: Payer Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

INDUSTRY NAME: Payer Country

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

SITUATIONAL RULE: Required when the address is not in the United States of America, including its territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to states, provinces, cantons, etc. If not required by this implementation guide, do not send.

INDUSTRY NAME: Payer Country Subdivision

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

REF - ADDITIONAL PAYER IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when additional payer identification numbers beyond those in the TRN and Payer N1 segments are needed to uniquely identify the payer to the provider. If not required by this implementation guide, do not send.

TR3 Notes:

The ID available in the TRN or N1 segments must be used before using the REF segment.

TR3 Example:

REF✱2U✱98765~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Payer Identification Number

Use when reporting the proprietary or legacy ID specific to the payer.

Health Industry Number (HIN)

CODE SOURCE: 121: Health Industry Number

National Association of Insurance Commissioners (NAIC) Code

CODE SOURCE: 245: National Association of Insurance Commissioners (NAIC) Code

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Additional Payer Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*EO - TRANSACTION CREATOR IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the original transaction creator is not the payer.
OR
Required when the original transaction creator has an identifier other than those already provided.
If not required by this implementation guide, do not send.

TR3 Notes:

This segment is not used by third parties between the payer and the payee.
An example of this segment's use includes, but is not limited to: identifying a clearinghouse that created the 835 when the health plan sent a proprietary format to the clearinghouse.

TR3 Example:

REF✱EO✱123345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Submitter Identification Number

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Transaction Creator Identifier

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

PER*CX - PAYER BUSINESS CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

To identify a person or office to whom administrative communications should be directed

X12 Syntax:

P0304
If either PER03 or PER04 is present, then the other is required.
P0506
If either PER05 or PER06 is present, then the other is required.
P0708
If either PER07 or PER08 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when there is a business contact area that would apply to this remittance and all the claims. If not required by this implementation guide, do not send.

TR3 Notes:

When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as 1, in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension, do not include data that indicates an extension, such as "ext" or "x-".

TR3 Example:

PER✱CX✱JOHN WAYNE✱TE✱8005551212✱EX✱4255~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

366

Contact Function Code

M 1

Code identifying the major duty or responsibility of the person or group named

CODE

DEFINITION

Payers Claim Office

Situational

Name

O 1

1/60

Free-form name

SITUATIONAL RULE: Required when it is necessary to identify an individual or other contact point to discuss information related to this transaction. If not required by this implementation guide, do not send.

INDUSTRY NAME: Payer Contact Name

Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1).

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Payer Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when a second communication contact number is needed. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Telephone Extension

Use when reporting a telephone extension for the preceding telephone number.

Facsimile

Telephone

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when a second communication contact number is needed. If not required by this implementation guide, do not send.

INDUSTRY NAME: Payer Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when an extension applies to the previous communications contact number (PER06). If not required by this implementation guide, do not send.

CODE

DEFINITION

Telephone Extension

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when an extension applies to the previous communications contact number (PER06). If not required by this implementation guide, do not send.

INDUSTRY NAME: Payer Contact Communication Number

Not Used

443

Contact Inquiry Reference

O 1

1/20

PER*BL - PAYER TECHNICAL CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

To identify a person or office to whom administrative communications should be directed

X12 Syntax:

P0304
If either PER03 or PER04 is present, then the other is required.
P0506
If either PER05 or PER06 is present, then the other is required.
P0708
If either PER07 or PER08 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

TR3 Example:

PER✱BL✱JOHN WAYNE✱TE✱8005551212✱EX✱123~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

366

Contact Function Code

M 1

Code identifying the major duty or responsibility of the person or group named

CODE

DEFINITION

Technical Department

Situational

Name

O 1

1/60

Free-form name

SITUATIONAL RULE: Required when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). If not required by this implementation guide, do not send.

INDUSTRY NAME: Payer Technical Contact Name

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Electronic Mail

Telephone

Uniform Resource Locator (URL)

Use when there is no central telephone number for the payer entity.

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Payer Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when an additional communication contact number is needed or an extension applies to the previous communications contact number. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Telephone Extension

Use when reporting a telephone extension for the preceding telephone number.

Facsimile

Telephone

Uniform Resource Locator (URL)

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

INDUSTRY NAME: Payer Technical Contact Communication Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

CODE

DEFINITION

Electronic Mail

Telephone Extension

Use when reporting a telephone extension for the preceding telephone number.

Facsimile

Uniform Resource Locator (URL)

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

INDUSTRY NAME: Payer Contact Communication Number

Not Used

443

Contact Inquiry Reference

O 1

1/20

PER*IC - PAYER WEBSITE CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

To identify a person or office to whom administrative communications should be directed

X12 Syntax:

P0304
If either PER03 or PER04 is present, then the other is required.
P0506
If either PER05 or PER06 is present, then the other is required.
P0708
If either PER07 or PER08 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when any 2110 loop Healthcare Policy REF Segment is used or 2100 loop Payment Determination Methodology REF Segment is used
AND
more details are available via the payer Website.
If not required by this implementation guide, do not send.

TR3 Notes:

This is a direct link to the policy location on payer's website (secured or unsecured) when any 2110 loop Healthcare Policy REF Segment is used.
This is a direct link to the fee schedule location on payer's website (secured or unsecured) when any 2100 loop Payment Determination Methodology REF Segment with qualifier AFT is used.

TR3 Example:

PER✱IC✱✱UR✱www.anyhealthplan.com/policies.html~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

366

Contact Function Code

M 1

Code identifying the major duty or responsibility of the person or group named

CODE

DEFINITION

Information Contact

Not Used

Name

O 1

1/60

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Uniform Resource Locator (URL)

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

This is the payer's website URL where providers can find policy and other related information.

Not Used

365

Communication Number Qualifier

X 1

Not Used

364

Communication Number

X 1

1/2048

Not Used

365

Communication Number Qualifier

X 1

Not Used

364

Communication Number

X 1

1/2048

Not Used

443

Contact Inquiry Reference

O 1

1/20

N1*PE - PAYEE IDENTIFICATION

X12 Name:

Party Identification

X12 Purpose:

To identify a party by type of organization, name, and code

X12 Syntax:

R0203
At least one of N102 or N103 is required.
P0304
If either N103 or N104 is present, then the other is required.
C0703
If N107 is present, then N103 is required.

X12 Set Notes:

COMMENT: The N1 loop allows for name/address information for the payer and payee which would be utilized to address remittance(s) for delivery.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Use this N1 loop to provide the name/address information of the payee. The identifying reference number (when applicable) is provided in N104.

TR3 Example:

N1✱PE✱MID-STATE MENTAL HOSPITAL✱XX✱12345678~

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Payee

Required

Name

X 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Payee Name

Situational

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: R0203, P0304, C0703

SITUATIONAL RULE: Required when N104 is used. If not required by this implementation guide, do not send.

See section 1.10.2.22 for additional information.

CODE

DEFINITION

Standard Unique Health Plan Identifier (HPID)

Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

CODE SOURCE: 540: Health Plan Identifier (HPID)

Standard Unique Health Identifier for Health Care Providers (NPI)

CODE SOURCE: 537: National Provider Identifier (NPI)

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when the payee has a National Provider Identifier (NPI) and a Billing / Pay-to National Provider Identifier (NPI) was submitted on the claim.ORRequired when reporting the Health Plan Identifier (HPID) or Other Entity Identifier (OEID).If not required by this implementation guide, do not send.See section 1.10.2.22 for additional information.

INDUSTRY NAME: Payee Identification Code

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

C076

Composite Identification Codes

O 1

N3 - PAYEE ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when BPR01 is equal to U or X and RDM01 is equal to BM where the sender needs to communicate the payee address to the transaction receiver. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

TR3 Example:

N3✱SUITE 200✱1000 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Payee Address Line

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when a second address line is needed. If not required by this implementation guide, do not send.

INDUSTRY NAME: Payee Address Line

N4 - PAYEE CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
E0308
Only one of N403 or N408 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Postal Code
Formatted

X 1

3/20

Required

City Name

O 1

2/30

Free-form text for city name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

INDUSTRY NAME: Payee City Name

Situational

156

State or Province Code

X 1

Code specifying the Standard State/Province as defined by appropriate government agency

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Payee State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

Code specifying international postal zone code excluding punctuation and blanks (zip code for United States)

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Payee Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

INDUSTRY NAME: Payee Country Code

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

INDUSTRY NAME: Payee Country Subdivision Code

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

REF - PAYEE ADDITIONAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when identification of the payee is dependent upon an identification number beyond that supplied in the N1 segment. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

TR3 Example:

REF✱PQ✱12345678~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License Number

National Council for Prescription Drug Programs Pharmacy Number

CODE SOURCE: 307: National Council for Prescription Drug Programs Pharmacy Provider Identification Number

Payee Identification

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Additional Payee Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*TJ - PAYEE TAX IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

REF✱TJ✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Federal Taxpayer's Identification Number

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Payee Tax Identification Number

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

RDM - REMITTANCE DELIVERY METHOD

X12 Name:

Remittance Delivery Method

X12 Purpose:

To identify remittance delivery when remittance is separate from payment

Loop:

Loop 2000 - HEADER NUMBER

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when BPR01 = U (Split Payment and Remittance) or X (Handling Party's Option to Split Payment and Remittance), and the remittance is to be sent separately from the payment. If not required by this implementation guide, do not send.

TR3 Notes:

Payer and Payee must coordinate this process with the third party processor.

TR3 Example:

RDM✱BM✱Third Party Processor Name~RDM✱OL✱✱www.anyhealthplan.com~

RDM

✱

✱

✱

✱

✱

Required

756

Report Transmission Code

M 1

1/2

Code specifing timing, transmission method or format by which reports are to be sent

CODE

DEFINITION

By Mail

Use when the remittance information will be mailed to the payee at the address identified in this 1000B loop.

E-Mail

Use when the remittance delivery method is encrypted e-mail.

File Transfer

Use when the remittance delivery method is FTP communications.

On-Line

Use when the remittance delivery method is secured hosted or other electronic delivery.

Situational

Name

O 1

1/60

Free-form name

COMMENT: RDM02 is used to contain the name of a third party processor if needed, who would be the first recipient of the remittance.

SITUATIONAL RULE: Required when RDM01 = BM (By Mail). If not required by this implementation guide, do not send.

INDUSTRY NAME: Remittance Recipient Name

When BM (By Mail) is used in RDM01, the remittance information will be mailed to the attention of this person at the payee's address identified in this 1000B loop.

Situational

364

Communication Number

O 1

1/2048

Complete communications number including country or area code when applicable

COMMENT: RDM03 contains the operative communication number for the delivery method specified in RDM01 (i.e. fax phone number and mail address).

SITUATIONAL RULE: Required when RDM01 equals EM (E-Mail), FT (File Transfer), or OL (On-Line). If not required by this implementation guide, do not send.

Contains URL web address, e-mail address, or FTP address.

Not Used

C040

Reference Identifier

O 1

Not Used

C040

Reference Identifier

O 1

LX - HEADER NUMBER

X12 Name:

Transaction Set Line Number

X12 Purpose:

To reference a line number in a transaction set

X12 Set Notes:

NOTE: The LX segment is used to provide a looping structure and logical grouping of claim payment information.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when claim/service information is being provided in the transaction. If not required by this implementation guide, do not send.

TR3 Notes:

The purpose of LX01 is to provide an identification of a particular grouping of claims for sorting purposes.
In the event that claim/service information must be sorted, the LX segment must precede each series of claim level and service level segments. This number is intended to be unique within each transaction.

TR3 Example:

LX✱1~

✱

Required

554

Assigned Number

M 1

1/9

Number assigned for differentiation within a transaction set

INDUSTRY NAME: Claim Grouping Identifier

TS3 - PROVIDER SUMMARY INFORMATION

X12 Name:

Transaction Statistics

X12 Purpose:

To supply provider-level control information

Loop:

Loop 2000 - HEADER NUMBER

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when there is a need to identify provider subsidiaries whose remittance information is contained in the 835 transaction transmitted to a single provider entity [e.g., the corporate office of a hospital chain]. If not required by this implementation guide, do not send.

TR3 Notes:

TS301 identifies the subsidiary provider.
The remaining mandatory elements (TS302 through TS305) must be valid with appropriate data, as defined by the TS3 segment.
Only Medicare uses data elements TS313, TS315, TS317, TS318 and TS320 through TS324. Each monetary amount element pertains to the provider identified in TS301.

TR3 Example:

TS3✱1234567890✱11✱20171031✱10✱130957.66~

TS3

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

127

Reference Identification

M 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: TS301 is the provider number.

INDUSTRY NAME: Provider Identifier

This is the provider number. When the provider has an NPI, this must be the provider's NPI.
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Required

1331

Facility Code Value

M 1

1/3

Code identifying where services were, or may be, performed; the National Uniform Billing Committee (NUBC) Facility Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.

INDUSTRY NAME: Facility Type Code

When reporting a TS3 segment for professional claims and the claims are not all for the same place of service, report a place of service of 11 (Office) as the default value. When reporting a TS3 segment for pharmaceutical claims and the claims are not all for the same place of service, report a place of service of 99 (Other unlisted facility) as the default value.

Required

373

Date

M 1

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

SEMANTIC: TS303 is the last day of the provider's fiscal year.

INDUSTRY NAME: Fiscal Period Date

This is the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known by the payer, use December 31st of the current year.

Required

380

Quantity

M 1

1/15

Numeric value of quantity

SEMANTIC: TS304 is the total number of claims.

INDUSTRY NAME: Total Claim Count

Total number of claims is defined as the total count of Claim Payment Information (CLP) segments in the current iteration of the 2000 Loop.

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: TS305 is the total of reported charges.

INDUSTRY NAME: Total Claim Charge Amount

The total of reported charges (Total Claim Charge Amount) is defined as the sum of the Total Claim Charge Amount (CLP03) in the Claim Payment Information (CLP) segments in the current iteration of the 2000 Loop.
Refer to Appendix B.1.1.3 for more information about decimal data elements.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Not Used

782

Monetary Amount

O 1

1/18

Not Used

782

Monetary Amount

O 1

1/18

Not Used

782

Monetary Amount

O 1

1/18

Not Used

782

Monetary Amount

O 1

1/18

Not Used

782

Monetary Amount

O 1

1/18

Not Used

782

Monetary Amount

O 1

1/18

Not Used

782

Monetary Amount

O 1

1/18

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: TS313 is the total Medicare Secondary Payer (MSP) primary payer amount.

SITUATIONAL RULE: Required when the total MSP Payer Amount is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total MSP Payer Amount

See TR3 note 3.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Not Used

782

Monetary Amount

O 1

1/18

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: TS315 is the summary of non-lab charges.

SITUATIONAL RULE: Required when the total Non-Lab charge amount is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total Non-Lab Charge Amount

See TR3 note 3.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Not Used

782

Monetary Amount

O 1

1/18

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: TS317 is the Healthcare Common Procedure Coding System (HCPCS) reported charges.

SITUATIONAL RULE: Required when the total HCPCS Reported Charge Amount is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total HCPCS Reported Charge Amount

See TR3 note 3.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: TS318 is the total Healthcare Common Procedure Coding System (HCPCS) payable amount.

SITUATIONAL RULE: Required when the total HCPCS payable amount is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total HCPCS Payable Amount

See TR3 note 3.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Not Used

782

Monetary Amount

O 1

1/18

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: TS320 is the total professional component amount.

SITUATIONAL RULE: Required when the total professional component amount is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total Professional Component Amount

The professional component amount must also be reported in the RAS segment with a Claim Adjustment Reason Code value of 89.
See TR3 note 3.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: TS321 is the total Medicare Secondary Payer (MSP) patient liability met.

SITUATIONAL RULE: Required when the total MSP patient liability met amount is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total MSP Patient Liability Met Amount

See TR3 note 3.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: TS322 is the total patient reimbursement.

SITUATIONAL RULE: Required when the total patient reimbursement amount is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total Patient Reimbursement Amount

See TR3 note 3.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: TS323 is the total periodic interim payment (PIP) number of claims.

SITUATIONAL RULE: Required when the Total PIP Claim Count is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total PIP Claim Count

See TR3 note 3.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: TS324 is total periodic interim payment (PIP) adjustment.

SITUATIONAL RULE: Required when the total PIP adjustment amount is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total PIP Adjustment Amount

See TR3 note 3.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

TS2 - PROVIDER SUPPLEMENTAL SUMMARY INFORMATION

X12 Name:

Transaction Supplemental Statistics

X12 Purpose:

To provide supplemental summary control information by provider fiscal year and bill type

Loop:

Loop 2000 - HEADER NUMBER

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required for Medicare Part A. If not required by this implementation guide, do not send.

TR3 Notes:

This segment provides summary information specific to an iteration of the LX loop (Table 2).
Each element represents the total value for the provider/bill type combination in this loop 2000 iteration.

TR3 Example:

TS2✱59786✱55375.77~

TS2

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: TS201 is the total diagnosis related group (DRG) amount.

SITUATIONAL RULE: Required when the value of the Total DRG amount is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total DRG Amount

This includes: operating federal-specific amount, operating hospital-specific amount, operating Indirect Medical Education amount, and operating Disproportionate Share Hospital amount. It does not include any operating outlier amount.
See TR3 note 2.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: TS202 is the total federal specific amount.

SITUATIONAL RULE: Required when total federal specific amount is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total Federal Specific Amount

See TR3 note 2.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: TS203 is the total hospital specific amount.

SITUATIONAL RULE: Required when total hospital specific amount is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total Hospital Specific Amount

See TR3 note 2.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: TS204 is the total disproportionate share amount.

SITUATIONAL RULE: Required when total disproportionate share amount is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total Disproportionate Share Amount

See TR3 note 2.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: TS205 is the total capital amount.

SITUATIONAL RULE: Required when total capital amount is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total Capital Amount

This includes: capital federal-specfic amount, hospital federal-specfic amount, hold harmless amount, Indirect Medical Education amount, Disproportionate Share Hospital amount, and the exception amount. It does not include any capital outlier amount.
See TR3 note 2.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: TS206 is the total indirect medical education amount.

SITUATIONAL RULE: Required when total indirect medical education amount is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total Indirect Medical Education Amount

See TR3 note 2.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: TS207 is the total number of outlier days.

SITUATIONAL RULE: Required when total outlier day count is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total Outlier Day Count

See TR3 note 2.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: TS208 is the total day outlier amount.

SITUATIONAL RULE: Required when the value of the total day outlier amount is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total Day Outlier Amount

See TR3 note 2.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: TS209 is the total cost outlier amount.

SITUATIONAL RULE: Required when the value of the total cost outlier amount is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total Cost Outlier Amount

See TR3 note 2.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: TS210 is the diagnosis related group (DRG) average length of stay.

SITUATIONAL RULE: Required when the value of the average DRG length of stay is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Average DRG Length of Stay

See TR3 note 2.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: TS211 is the total number of discharges.

SITUATIONAL RULE: Required when the value of the total discharge count is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total Discharge Count

This is the discharge count produced by PPS PRICER SOFTWARE.
See TR3 note 2.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: TS212 is the total number of cost report days.

SITUATIONAL RULE: Required when the value of the total cost report day count is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total Cost Report Day Count

See TR3 note 2.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: TS213 is the total number of covered days.

SITUATIONAL RULE: Required when the value of the total covered day count is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total Covered Day Count

See TR3 note 2.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: TS214 is total number of non-covered days.

SITUATIONAL RULE: Required when the value of the total non-covered day count is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total Noncovered Day Count

See TR3 note 2.
See sections 1.10.2.4.2 and 1.10.2.4.6 for additional information.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: TS215 is the total Medicare Secondary Payer (MSP) pass- through amount calculated for a non-Medicare payer.

SITUATIONAL RULE: Required when the value of the total MSP Pass-through amount is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total MSP Pass-Through Amount

See TR3 note 2.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: TS216 is the average diagnosis-related group (DRG) weight.

SITUATIONAL RULE: Required when the value of the average DRG Weight is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Average DRG weight

See TR3 note 2.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: TS217 is the total prospective payment system (PPS) capital, federal-specific portion, diagnosis-related group (DRG) amount.

SITUATIONAL RULE: Required when the value of the total PPS capital FSP (Federal-specific Portion) DRG amount is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total PPS Capital FSP DRG Amount

See TR3 note 2.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: TS218 is the total prospective payment system (PPS) capital, hospital-specific portion, diagnosis-related group (DRG) amount.

SITUATIONAL RULE: Required when the value of the total PPS Capital HSP (Hospital-specific Portion) DRG Amount is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total PPS Capital HSP DRG Amount

See TR3 note 2.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: TS219 is the total prospective payment system (PPS) disproportionate share, hospital diagnosis-related group (DRG) amount.

SITUATIONAL RULE: Required when the value of the total PPS Capital DSH (Disproportionate Share, Hospital) DRG amount is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Total PPS DSH DRG Amount

See TR3 note 2.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

CLP - CLAIM PAYMENT INFORMATION

X12 Name:

Claim Level Data

X12 Purpose:

To supply information common to all services of a claim

X12 Syntax:

P1112
If either CLP11 or CLP12 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

CLP✱7722337✱1✱211366.97✱138018.4✱✱✱119932404007801✱11✱1✱✱DCM:123✱✱✱✱✱72~

CLP

✱

1028

Claim Submt
Identifier

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Health Care
Code Info.

✱

✱

✱

Yes/No Cond
Resp Code

✱

✱

Required

1028

Claim Submitter's Identifier

M 1

1/38

Identifier used to track a claim from creation by the health care provider through payment

INDUSTRY NAME: Provider's Assigned Claim Identifier

Use this number for the Provider's Assigned Claim Identifier. If the Provider's Assigned Claim Identifier is not present on the incoming claim, enter a single zero. The value in CLP01 must be identical to any value received as the Provider's Assigned Claim Identifier on the original claim (characters 1-35 of the CLM01 of the ASC X12 837, if applicable). This data element is the primary key for posting the remittance information into the provider's database. In the case of pharmacy claims, refer to the NCPDP Pharmacy Reference Guide to the X12/007030X322 Health Care Claim Payment/Advice (835), available from NCPDP at http://www.ncpdp.org.

This identifier is generated by the provider for the purposes of reassociation to their claim accounts receivable, and must not be modified. This identifier, as submitted in the 837, is returned in 835 and/or other transactions. This identifier is not to be validated beyond standard TR3 syntax and semantic rules.

Required

1029

Claim Status Code

M 1

1/2

Code identifying the status of an entire claim as assigned by the payor, claim review organization or repricing organization

To determine the full claim status reference Claim adjustment reason codes in the RAS segment in conjunction with this claim status code.

CODE

DEFINITION

Processed as Primary

Use when the claim was adjudicated by the current payer as primary regardless of whether any part of the claim was paid. If the claim was rejected because the payer believes they are not primary, use the appropriate code for secondary or tertiary processing.

Processed as Secondary

Use when the claim was adjudicated by the current payer as secondary regardless of whether any part of the claim was paid OR the claim was denied because the payer determined that they should be secondary. Refer to the LoopID 2105 Corrected Priority Payer Name N1 segment requirements for additional information.

Processed as Tertiary

Use when the claim was adjudicated by the current payer as tertiary regardless of whether any part of the claim was paid OR the claim was denied because the payer determined that they should be tertiary. Refer to the LoopID 2105 Corrected Priority Payer Name N1 segment requirements for additional information.

Processed as Primary, Forwarded to Additional Payer(s)

Use when the claim was adjudicated by the current payer as primary regardless of whether any part of the claim was paid and the claim was forwarded to another payer(s). If the claim was rejected because the payer believes they are not primary, use the appropriate code for secondary or tertiary processing. When this code is used, the Crossover Carrier Name NM1 segment is required.

Processed as Secondary, Forwarded to Additional Payer(s)

Use when the claim was forwarded to another payer(s) and the claim was adjudicated by the current payer as secondary regardless of whether any part of the claim was paid, or when a primary claim was denied because the payer determined that they should be secondary. When this code is used, the Crossover Carrier Name NM1 segment is required.

Processed as Tertiary, Forwarded to Additional Payer(s)

Use when the claim was forwarded to another payer(s) and the claim was adjudicated by the current payer as tertiary (or subsequent) regardless of whether any part of the claim was paid or when a primary or secondary claim was denied because the payer determined that they should be tertiary (or subsequent). When this code is used, the Crossover Carrier Name NM1 segment is required.

Not Our Claim, Forwarded to Additional Payer(s)

Use when the patient/subscriber is not recognized, the claim was not adjudicated by the payer, but other payers are known and the claim has been forwarded to another payer. When this code is used, the Crossover Carrier Name NM1 segment is required.

Predetermination Pricing Only - No Payment

Use when responding to a predetermination request. See section 1.10.2.7 for additional information.

Reversal of Previous Payment for Primary Claim

Use when identifying a reversal of a previous payment for a Primary claim. See Section 1.10.2.8 for usage information

Reversal of Previous Payment for Secondary Claim

Use when identifying a reversal of a previous payment for a Secondary claim. See Section 1.10.2.8 for usage information.

Reversal of Previous Payment of Tertiary Claim

Use when identifying a reversal of a previous payment for a Tertiary (or subsequent) claim. See Section 1.10.2.8 for usage information.

Patient/Subscriber Not Recognized

Use when the Patient/Subscriber is not recognized, and the claim was not forwarded to another payer.

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: CLP03 is the amount of submitted charges this claim.

INDUSTRY NAME: Total Claim Charge Amount

Use this monetary amount for the submitted charges for this claim. The amount can be positive, zero or negative. An example of a situation with a negative charge is a reversal claim. See section 1.10.2.8 for additional information.
See 1.10.2.1.2, Claim Balancing, in this implementation guide for additional information.
Refer to Appendix B.1.1.3 for more information about decimal data elements.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: CLP04 is the amount paid this claim.

INDUSTRY NAME: Claim Payment Amount

See 1.10.2.1.2, Claim Balancing, in this implementation guide for additional information.
Use this monetary amount for the amount paid for this claim. It can be positive, zero or negative, but the value in BPR02 may not be negative.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CLP05 is the patient responsibility amount.

SITUATIONAL RULE: Required when any 2100 or 2110 Loop RAS segment has a Claim Adjustment Group code (RAS02) indicating Patient Responsibility and the sum of the associated monetary Adjustment Amount (RAS01) values is not equal to zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Responsibility Amount

Amounts in CLP05 must have supporting adjustments reflected in RAS segments at the 2100 or 2110 loop level with a Claim Adjustment Group Code (RAS02) indicating Patient Responsibility. Amounts associated with Claim Adjustment Group Codes other than Patient Responsibility (e.g. Payer Initiated) should not be included.
Use this monetary amount for the payer's statement of the patient responsibility amount for this claim, which can include such items as deductible, non-covered services, co-pay and co-insurance. See section 1.10.2.8, Reversals and Corrections, for additional information.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Not Used

1032

Claim Filing Indicator Code

O 1

1/2

Required

127

Reference Identification

O 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: CLP07 is the payer's internal control number.

INDUSTRY NAME: Payer Claim Control Number

Use this number for the payer's internal control number. This number must apply to the entire claim.
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Situational

1331

Facility Code Value

O 1

1/3

SITUATIONAL RULE: Required when the information was received on the original claim. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

INDUSTRY NAME: Facility Type Code

This number was received in CLM05-01 of the 837 claim.
Since professional or dental claims can have different place of service codes for services within a single claim, default to the place of service of the first service line when the service lines are not all for the same place of service.

Situational

1325

Claim Frequency Type Code

O 1

Code specifying the Type of Bill Frequency Code. It is the last digit of Type of Bill in the UB manual, as defined by the National Uniform Billing Committee

INDUSTRY NAME: Claim Frequency Code

This number was received in CLM05-03 of the 837 Claim.

CODE SOURCE 235: Claim Frequency Type Code

Not Used

1352

Patient Discharge Status

O 1

1/2

Situational

C022

Health Care Code Information

X 1

To send health care codes and their associated dates, amounts and quantities

SEMANTIC: CLP11 is used to convey diagnostic related group code.

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06, C022-08 and C022-10.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
C022-10 is the attribute of the code in C022-02 from the same code list.

X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.

SITUATIONAL RULE: Required when a DRG or grouping methodology was used to adjudicate the claim. If not required by this implementation guide, do not send.

Required

11-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

Use this field to report the DRG type qualifier used to adjudicate the claim.

CODE

DEFINITION

ABS

Assigned by Sender

All Patient Refined Diagnosis Related Groups (APR-DRG)

CODE SOURCE: 477: All Patient Refined Diagnosis Related Groups (APR-DRG)

All Patient Diagnosis Related Groups (AP-DRG)

CODE SOURCE: 476: All Patient Diagnosis Related Groups (AP-DRG)

Ambulatory Patient Groups (APG)

CODE SOURCE: 475: Ambulatory Patient Groups (APG)

DAP

All Patient, Severity-Adjusted DRGs (APS-DRG)

DCM

Medicare DRG (CMS-DRG & MS-DRG)

DIR

International-Refined DRGs (IR-DRG)

Diagnosis Related Group (DRG)

DRD

Refined DRGs (R-DRG)

DSD

Severity DRGs (S-DRG)

Enhanced Ambulatory Patient Groups (EAPG)

CODE SOURCE: 980: Enhanced Ambulatory Patient Groups

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

Use this field to report the DRG code or grouping methodology used to adjudicate the claim.

Not Used

11-3

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

11-4

1251

Date Time Period

X 1

1/35

Not Used

11-5

782

Monetary Amount

O 1

1/18

Not Used

11-6

380

Quantity

O 1

1/15

Not Used

11-7

799

Version Identifier

O 1

1/30

Not Used

11-8

1271

Industry Code

X 1

1/30

Not Used

11-9

1271

Industry Code

X 1

1/30

Not Used

11-10

1271

Industry Code

O 1

1/30

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEMANTIC: CLP12 is the diagnosis-related group (DRG) weight.

SEGMENT SYNTAX: P1112

SITUATIONAL RULE: Required for institutional claims when the claim was adjudicated using a DRG (CLP11-01 is present and not equal to AX or EP). If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Related Group (DRG) Weight

This is the adjudicated DRG weight for the DRG reported in CLP11. When the payer does not consider DRG Weight during adjudication, populate this element with "1".

Situational

954

Percentage as Decimal

O 1

1/10

Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)

SEMANTIC: CLP13 is the discharge fraction.

SITUATIONAL RULE: Required when a discharge fraction was applied in the adjudication process. If not required by this implementation guide, do not send.

INDUSTRY NAME: Discharge Fraction

This is the adjudicated discharge fraction for the DRG reported in CLP11.

Not Used

1073

Yes/No Condition or Response Code

O 1

Situational

280

Exchange Rate

O 1

4/10

Value to be used as a multiplier conversion factor to convert monetary value from one currency to another

SITUATIONAL RULE: Required when the currency of the originally submitted claim is different than the currency of adjudication/payment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Exchange Rate

This is the exchange rate used by the payer when converting from the original submitted currency to the adjudication/payment currency. For instance if a submitted charge of 100 British Pounds was converted to $125 then the exchange rate reported would be 1.250.

Required

1732

Source of Payment Typology Code

O 1

2/6

Code identifying payer types in the most granular way

SEMANTIC: CLP16 is the Source of Payment Typology Code (see Code Source 944).

The Source of Payment Typology provides a standard for reporting the payer and the payer's product. The source of payment type is determined by the organization that provides the payment and must be reported using the most granular level of detail defining the payer and the payer's product.

CODE SOURCE 944: Source of Payment Typology

RAS - CLAIM ADJUSTMENT INFORMATION

X12 Name:

Reason Adjustment

X12 Purpose:

To supply Claim Adjustment Reason Codes and amounts as needed for an entire claim or for a particular service within the claim being paid

X12 Comments:

Adjustment information is intended to help the provider balance the remittance information. Adjustment amounts must fully explain the difference between submitted charges and the amount paid.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when dollar amounts are being adjusted at the claim level. If not required by this implementation guide, do not send.

TR3 Notes:

Payers must use this RAS segment to report claim level adjustments that cause the amount paid to differ from the amount originally charged. See sections 1.10.2.1, Financial Balancing, and 1.10.2.4, Claim Adjustment Information and Service Adjustment Information Segment Theory, for additional information.
See the SVC TR3 Note #2 for details about per diem adjustments.

TR3 Example:

RAS✱125.32✱PR✱1~RAS✱25✱PR✱3~RAS✱200✱CO✱6^7~RAS✱500✱CO✱45:HE:N13✱1~RAS✱1225✱CO✱16:HE:M24^15:HE:N517✱2~RAS✱2225✱CO✱16:HE:M44:M45:M49^146:HE:MA63:MA65~RAS✱2100✱OA✱18:HE:N522:N702~

RAS

✱

✱

Claim Adjst
Group Code

✱

✱

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: RAS01 is the amount of adjustment.

INDUSTRY NAME: Adjustment Amount

Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in CLP04. This amount must not be zero (0).
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Required

1785

Claim Adjustment Group Code

M 1

1/10

Code identifying the general category of payment adjustment.

Evaluate the usage of group codes in RAS02 based on the following order for their applicability to an adjustment: Patient Responsibility, Contractual Obligation, Payer Initiated, Other Adjustments. (Note: This does not mean that the adjustments must be reported in this order.)

See Front Matter Section 1.10.2.4.5, Claim Adjustment Group Code Usage, for additional information.

CODE SOURCE 974: Claim Adjustment Group Codes

Required

C058

Adjustment Reason

M 15

To provide a reason and related explanation for a Health Care Claim or Service change in payment versus the original submitted charges

SEMANTIC: Position of data in the repeating composite data element conveys no significance.

X12 COMPOSITE SYNTAX NOTES:

P0203
If either C05802 or C05803 is present, then the other is required.
C0403
If C05804 is present, then C05803 is required.
C0504
If C05805 is present, then C05804 is required.
C0605
If C05806 is present, then C05805 is required.
C0706
If C05807 is present, then C05806 is required.

X12 COMPOSITE SEMANTIC NOTES: C05802 qualifies C05803, C05804, C05805, C05806 and C05807.

More than one iteration of this composite may be provided only when the entire claim submitted charge (CLP03) is being adjusted by this RAS segment (RAS01 equals CLP03) and there are multiple adjustment reasons that are each applicable to the full amount in RAS01.

See 1.10.2.4.2 Claim/Service Adjustment Information Segment for additional information.
This composite identifies the reason for the adjustment of the dollar amount identified in RAS01.

Required

3-1

1034

Claim Adjustment Reason Code

M 1

1/5

Code identifying the detailed reason the adjustment was made

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

3-2

1270

Code List Qualifier Code

X 1

1/3

Code identifying a specific industry code list

COMPOSITE SYNTAX: P0203

SITUATIONAL RULE: Required when a remark code is necessary for the provider to fully understand the adjustment message for the claim adjustment reason identified in RAS03-01. If not required by this implementation guide, do not send.

CODE

DEFINITION

Remittance Advice Remark Code

CODE SOURCE: 411: Remittance Advice Remark Code

Insurance Industry Specific Remark Codes

CODE SOURCE: 973: Insurance Industry Specific Remark Codes

Situational

3-3

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: P0203, C0403

INDUSTRY NAME: Remark Code

Remark codes that include "Alert" in their description are not reported in the RAS segment, but in the LQ segment at the appropriate level.

Situational

3-4

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: C0403, C0504

SITUATIONAL RULE: Required when an additional remark code not already provided in this composite is necessary for the provider to fully understand the adjustment message for the claim adjustment reason identified in RAS03-01. If not required by this implementation guide, do not send.

INDUSTRY NAME: Remark Code

Remark codes that include "Alert" in their description are not reported in the RAS segment, but in the LQ segment at the appropriate level.

Situational

3-5

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: C0504, C0605

INDUSTRY NAME: Remark Code

Remark codes that include "Alert" in their description are not reported in the RAS segment, but in the LQ segment at the appropriate level.

Situational

3-6

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: C0605, C0706

INDUSTRY NAME: Remark Code

Remark codes that include "Alert" in their description are not reported in the RAS segment, but in the LQ segment at the appropriate level.

Situational

3-7

1271

Industry Code

O 1

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: C0706

INDUSTRY NAME: Remark Code

Remark codes that include "Alert" in their description are not reported in the RAS segment, but in the LQ segment at the appropriate level.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: RAS04 is the units of service being adjusted.

SITUATIONAL RULE: Required when the RAS03 adjustment reason code is related to non-covered days. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

A positive value decreases the quantity, and a negative value increases the quantity.

NM1*QC - PATIENT NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Any necessary identification number should be provided in NM109.
This segment must provide the information from the original claim. For example, when the claim is submitted as an ASC X12 837 transaction, this is the 2010CA loop NM1 Patient Name Segment unless not present on the original claim, then it is the 2010BA loop NM1 Subscriber name segment.
The Corrected Patient/Subscriber Name NM1 segment identifies the adjudicated Subscriber Name and ID information if different than what was submitted on the claim.

TR3 Example:

NM1✱QC✱1✱Shepard✱Sam✱A✱✱✱MI✱452114586~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Patient

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Situational

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when the claim is not a retail pharmacy claimORRequired when the claim is a retail pharmacy claim and the information was provided on the original claim.If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the patient has a first name and was provided on the original claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when the patient's middle name or initial was provided on the original claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Middle Name or Initial

If this data element is used and contains only one character, it is assumed to represent the middle initial.

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when the patient's suffix was provided on the original claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when NM109 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Standard Unique Health Identifier for each Individual in the United States

Use when reporting the HIPAA Individual Patient Identifier.

Member Identification Number

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when the Patient identifier was provided on the original claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

NM1*IL - SUBSCRIBER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the claim reported the insured or subscriber (for example 837 2010BA loop Subscriber Name NM1 Segment) that is different from the patient. If not required by this implementation guide, do not send.

TR3 Notes:

In the case of Medicare and Medicaid, the insured patient is always the subscriber and this segment is not used.
This segment contains the same information as submitted on the claim (for example 837 2010BA loop Subscriber Name NM1 Segment when the patient was reported in the 2010CA loop Patient Name NM1 Segment)
The Corrected Patient/Subscriber Name NM1 segment identifies the adjudicated Subscriber Name and ID information if different than what was submitted on the claim.

TR3 Example:

NM1✱IL✱1✱Shephard✱Jessica✱✱✱✱MI✱452114458~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Insured or Subscriber

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when submitted on the claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the subscriber is a person (NM102=1) and the first name was provided on the original claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when the subscriber is a person (NM102=1) AND the middle name or initial was provided on the claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Middle Name or Initial

If this data element is used and contains only one character, it is assumed to represent the middle initial.

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when the subscriber is a person (NM102=1) AND the suffix was provided on the original claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when NM109 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Federal Taxpayer's Identification Number

Use when NM102 = 2 and the Federal Taxpayer's Identifier is the primary identifier.

Standard Unique Health Identifier for each Individual in the United States

Use when reporting the HIPAA Individual Patient Identifier.

Member Identification Number

Use when indicating the subscriber's identification number as assigned by the payer. (For example, Insureds ID, Subscribers ID, Health Insurance Claim Number (HIC), etc.).

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when the Identification Code was provided on the claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

NM1 - CORRECTED PATIENT/SUBSCRIBER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the information submitted on the claim is different from the information on file with the payer. If not required by this implementation guide, do not send.

TR3 Notes:

Use this NM1 segment to provide information as it exists in the payer system. All portions of the name must be sent (NM103, NM104, and NM105) when information exists in the payer's system.

TR3 Example:

NM1✱COS✱1✱Shepard✱Sam✱A✱✱✱IN✱452114586~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

COP

Corrected Patient

COS

Corrected Subscriber

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when the adjudicated patient/subscriber last or organization name is different than the last or organization name submitted on the claim, or when NM104 and NM105 are being sent and the information exists in the payer's system. If not required by this implementation guide, do not send.

INDUSTRY NAME: Corrected Patient or Subscriber Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the patient/subscriber is a person and has a first name and the adjudicated first name is different than the first name submitted on the claim, or when NM103 and NM105 are being sent and the information exists in the payer's system. If not required by this implementation guide, do not send.

INDUSTRY NAME: Corrected Patient or Subscriber First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when the patient/subscriber is a person and has a middle name and the adjudicated middle name is different than the middle name submitted on the claim, or when NM103 and NM104 are being sent and the information exists in the payer's system. If not required by this implementation guide, do not send.

INDUSTRY NAME: Corrected Patient or Subscriber Middle Name or Initial

If this data element is used and contains only one character, it is assumed to represent the middle initial.

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when the patient/subscriber is a person and has a name suffix and the adjudicated name suffix is different than the name suffix submitted on the claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Corrected Patient or Subscriber Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when NM109 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Changed Unique Identification Number

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when the adjudicated patient/subscriber identification number is different than the identification submitted on the claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Corrected Patient or Subscriber Identification Number

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

NM1*SJ - SERVICE PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the service provider is different from the payee. If not required by this implementation guide, do not send.

TR3 Notes:

This information is provided to facilitate identification of the claim within a payee's system. Other providers (e.g., Referring provider, supervising provider) related to the claim but not directly related to the payment are not supported and are not necessary for claim identification.

TR3 Example:

NM1✱SJ✱2✱Service Physicians Inc✱✱✱✱✱XX✱6201254569~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Service Provider

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when the information was provided on the original claim. If not required, may be provided at sender's discretion, but cannot be required by the receiver.

INDUSTRY NAME: Service Provider Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the Service Provider is a person (NM102=1), NM103 is used AND the information is known by the sender. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when the Service Provider is a person (NM102=1), NM103 is used AND the information is known by the sender. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider Middle Name or Initial

If this data element is used and contains only one character, it is assumed to represent the middle initial.

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when the Service Provider is a person (NM102=1), NM103 is used, and the name suffix is necessary to identify the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when NM109 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Standard Unique Health Identifier for Health Care Providers (NPI)

CODE SOURCE: 537: National Provider Identifier (NPI)

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required for providers in the United States or its territories when the provider is eligible to receive a National Provider Identifier (NPI).ORRequired for providers not in the United States or its territories when the provider has received an NPI. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

NM1*TT - CROSSOVER CARRIER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the claim is transferred to another carrier or coverage (CLP02 equals 19, 20, 21 or 23). If not required by this implementation guide, do not send.

TR3 Notes:

This segment provides information about the crossover carrier. Provide any reference numbers in NM109. The crossover carrier is defined as any payer to which the claim is transferred for further payment after being finalized by the current payer.
When the claim is transferred to more than 1 carrier, use this segment to report all crossover names and reference numbers.

TR3 Example:

NM1✱TT✱2✱ACME INSURANCE✱✱✱✱✱XV✱123456789~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Transfer To

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Crossover Carrier Name

Name of the crossover carrier associated with this claim.

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Required

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Blue Cross Blue Shield Association Plan Code

Federal Taxpayer's Identification Number

National Association of Insurance Commissioners (NAIC) Identification

This is the preferred ID unless XV is used.

Payor Identification

Pharmacy Processor Number

Standard Unique Health Plan Identifier (HPID)

Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

CODE SOURCE: 540: Health Plan Identifier (HPID)

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Crossover Carrier Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

MIA - INPATIENT ADJUDICATION INFORMATION

X12 Name:

Inpatient Adjudication

X12 Purpose:

To provide claim level data related to the adjudication of inpatient claims

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required for all inpatient claims when the claim is paid by Medicare or Medicaid under the Prospective Payment System (PPS). If not required by this implementation guide, do not send.

TR3 Notes:

Either MIA or MOA may appear, but not both.
All situational quantities and/or monetary amounts in this segment are required when the value of the item is different than zero.

TR3 Example:

MIA✱✱✱✱0138018.4~

MIA

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Not Used

380

Quantity

O 1

1/15

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MIA02 is the Prospective Payment System (PPS) Operating Outlier amount.

SITUATIONAL RULE: Required when an additional payment is made for excessive cost incurred by the provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: PPS Operating Outlier Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: MIA03 is the lifetime psychiatric days.

SITUATIONAL RULE: Required for psychiatric claims when the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Lifetime Psychiatric Days Count

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MIA04 is the Diagnosis Related Group (DRG) amount.

SITUATIONAL RULE: Required for claims paid under a Diagnostic Related Group when the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim DRG Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Not Used

127

Reference Identification

O 1

1/80

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MIA06 is the disproportionate share amount.

SITUATIONAL RULE: Required when the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Disproportionate Share Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MIA07 is the Medicare Secondary Payer (MSP) pass-through amount.

SITUATIONAL RULE: Required when the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim MSP Pass-through Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MIA08 is the total Prospective Payment System (PPS) capital amount.

SITUATIONAL RULE: Required when the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim PPS Capital Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount.

SITUATIONAL RULE: Required when the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: PPS-Capital FSP DRG Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount.

SITUATIONAL RULE: Required when the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: PPS-Capital HSP DRG Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount.

SITUATIONAL RULE: Required when the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: PPS-Capital DSH DRG Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MIA12 is the old capital amount.

SITUATIONAL RULE: Required when the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Old Capital Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount.

SITUATIONAL RULE: Required when the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: PPS-Capital IME amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MIA14 is hospital specific Diagnosis Related Group (DRG) Amount.

SITUATIONAL RULE: Required when the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: PPS-Operating Hospital Specific DRG Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: MIA15 is the cost report days.

SITUATIONAL RULE: Required when the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Cost Report Day Count

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MIA16 is the federal specific Diagnosis Related Group (DRG) amount.

SITUATIONAL RULE: Required when the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: PPS-Operating Federal Specific DRG Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MIA17 is the Prospective Payment System (PPS) Capital Outlier amount.

SITUATIONAL RULE: Required when the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim PPS Capital Outlier Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MIA18 is the indirect teaching amount.

SITUATIONAL RULE: Required when the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Indirect Teaching Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MIA19 is the professional component amount billed but not payable.

SITUATIONAL RULE: Required when the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Nonpayable Professional Component Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Not Used

127

Reference Identification

O 1

1/80

Not Used

127

Reference Identification

O 1

1/80

Not Used

127

Reference Identification

O 1

1/80

Not Used

127

Reference Identification

O 1

1/80

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MIA24 is the capital exception amount.

SITUATIONAL RULE: Required when the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: PPS-Capital Exception Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

MOA - OUTPATIENT ADJUDICATION INFORMATION

X12 Name:

Outpatient Adjudication

X12 Purpose:

To provide claim level data related to the adjudication of outpatient claims

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required for outpatient/professional claims when the payer is Medicare or Medicaid and MOA01, 02, 08 or 09 are non-zero. If not required by this implementation guide, do not send.

TR3 Notes:

Either MIA or MOA may appear, but not both.
All situational quantities and/or monetary amounts in this segment are required when the value of the item is different than zero.

TR3 Example:

MOA✱50✱100~

MOA

✱

✱

✱

✱

✱

✱

✱

✱

✱

Situational

954

Percentage as Decimal

O 1

1/10

Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)

SEMANTIC: MOA01 is the reimbursement rate.

SITUATIONAL RULE: Required when the outpatient institutional claim reimbursement rate is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Reimbursement Rate

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MOA02 is the claim Healthcare Common Procedure Coding System (HCPCS) payable amount.

SITUATIONAL RULE: Required when the outpatient institutional claim HCPCS Payable Amount is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim HCPCS Payable Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Not Used

127

Reference Identification

O 1

1/80

Not Used

127

Reference Identification

O 1

1/80

Not Used

127

Reference Identification

O 1

1/80

Not Used

127

Reference Identification

O 1

1/80

Not Used

127

Reference Identification

O 1

1/80

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MOA08 is the End Stage Renal Disease (ESRD) payment amount.

SITUATIONAL RULE: Required when the outpatient institutional claim ESRD Payment Amount is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim ESRD Payment Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MOA09 is the professional component amount billed but not payable.

SITUATIONAL RULE: Required when the outpatient institutional claim Nonpayable Professional Component Amount is not zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Nonpayable Professional Component Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

REF - OTHER CLAIM RELATED IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when reference identifiers specified in REF01 are applicable to the claim, used in the adjudication process, or a result of the adjudication process. If not required by this implementation guide, do not send.

TR3 Example:

REF✱EA✱44444TH56~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Group or Policy Number

Employee Identification Number

Citation of Statute

Use when reporting the jurisdiction rule/statute reference identification number. If used, the PER Workers Compensation Website segment is required to provide an un-secure WEB contact point where the provider can access the full text description of the jurisdiction rule /statute reference.

Repriced Claim Reference Number

Adjusted Repriced Claim Reference Number

Medical Record Identification Number

Insurance Policy Number

Medical Assistance Category

Use when advising the provider of the Prepaid Medical Assistance Program (PMAP) code which was used for claim adjudication.

Statement Number

Use when reporting Jurisdiction/payer remittance statement number.

Agency Claim Number

Use when reporting the Property & Casualty Claim Number.

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Other Claim Related Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*F8 - ORIGINAL PAYER CLAIM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the payment is for a corrected claim and Payer Claim Control Number (CLP07) is different than the previous Payer Claim Control Number (CLP07) of the original claim payment / reversal related to this correction. If not required by this implementation guide, do not send.

TR3 Notes:

See section 1.10.2.8, Reversals and Corrections, for additional information.

TR3 Example:

REF✱F8✱24693640801286913~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Original Reference Number

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Original Payer Claim Control Number

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*CE - CLASS OF CONTRACT CODE

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the adjudication of the claim or services was impacted by the terms of a contract with the healthcare provider or by regulation. If not required by this implementation guide, do not send.

TR3 Notes:

Payers must develop the identifiers necessary to relay the plan information to the payee. The identifiers must be global, rather than payee-specific. Payers must provide a method to communicate the identifiers to payees in a timely fashion.

TR3 Example:

REF✱CE✱Network A~REF✱CE✱Network A✱✱2U:123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

See section 1.10.2.15 for information on the use of Class of Contract Code.

CODE

DEFINITION

Class of Contract Code

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Class of Contract Code

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Situational

C040

Reference Identifier

O 1

To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier

SEMANTIC: REF04 contains data relating to the value cited in REF02.

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C04003 or C04004 is present, then the other is required.
P0506
If either C04005 or C04006 is present, then the other is required.

SITUATIONAL RULE: Required when the entity that contracts directly with the health care provider is not the same as the payer identified in Loop 1000A and information is known and allowable to supply. If not required by this implementation guide, do not send.

Required

4-1

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Payer Identification Number

Required

4-2

127

Reference Identification

M 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

INDUSTRY NAME: Contracting Entity Payer Identifier

This is the identifier of the entity that assigned the Class of Contract Code in REF02 (the entity who is the party to the contract with the provider). This is the Health Plan Identifier (HPID) when mandated for use and the entity has a Health Plan Identifier (HPID). Otherwise, it is the Federal Tax ID of the entity. This ID is used by the provider with the Class of Contract Code to uniquely identify the contract or regulatory requirement that establishes the payment basis for this claim.
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

4-3

128

Reference Identification Qualifier

X 1

2/3

Not Used

4-4

127

Reference Identification

X 1

1/80

Not Used

4-5

128

Reference Identification Qualifier

X 1

2/3

Not Used

4-6

127

Reference Identification

X 1

1/80

REF - SERVICE PROVIDER SECONDARY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when additional service provider identification numbers not already reported in the Provider NM1 segment for this claim were submitted on the original claim and impacted adjudication. If not required by this implementation guide, do not send.

TR3 Notes:

The NM1 segment always contains the primary reference number.

TR3 Example:

REF✱LU✱12345678~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Identifier

This code designates a proprietary provider number assigned by the payer identified in the payer name loop (1000A) associated with this claim. This is true regardless of whether the payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a Commercial plan, or any other health plan.

Location Number

Federal Taxpayer's Identification Number

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Service Provider Secondary Identification

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF - PAYMENT DETERMINATION METHODOLOGY

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required for non-pharmacy claims when the "Payment Determination Methodology" identified by the REF01 qualifier was used to adjudicate and derive the allowed amount for the claim. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment to convey information related to pricing. CLP11 is used for information related to clinical grouping (e.g. DRG).

TR3 Example:

REF✱9V✱TSUR~REF✱APC✱6541~REF✱AFT✱033214~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Payment Category

Use when reporting payer specific payment determination methodologies identified in REF02. For example, use when reporting various tiers, rates, per diems, or percentage of charge. These are examples and should not be considered the only payment determination methodologies that can be used with this qualifier.

AFT

Fee Schedule Identifier

Use when advising the provider of the contracting entity's agreed upon enumerated fee schedule identifier for the specific fee schedule/contract that was used to adjudicate and derive the allowed amount for the services. If the contracting entity has the fee schedule on their website, the URL must be supplied in the Payer Website Contact Information PER at 1000A loop.

APC

Ambulatory Payment Classification

CODE SOURCE: 468: Ambulatory Payment Classification

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Payment Determination Methodology

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*BLT - ORIGINAL CLAIM INFORMATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment reports the type and method of claim originally submitted by the provider. It provides information needed in this transaction to split the file as needed and post to the accounts receivable system.

TR3 Example:

REF✱BLT✱P✱✱PHC:E~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

BLT

Billing Type

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Original Claim Type

The information in this field must reflect the original claim type received by the payer. Codes reported in REF02 must be one of the following:
Code Description
P Professional
IP Institutional Inpatient
OP Institutional Outpatient
D Dental
RX Pharmacy

Not Used

352

Description

X 1

1/80

Required

C040

Reference Identifier

O 1

To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier

SEMANTIC: REF04 contains data relating to the value cited in REF02.

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C04003 or C04004 is present, then the other is required.
P0506
If either C04005 or C04006 is present, then the other is required.

Required

4-1

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

PHC

Process Handling Code

Required

4-2

127

Reference Identification

M 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

INDUSTRY NAME: Method of Claim Submission

The information reported in this element must reflect the method in which the claim reported in this CLP was received by the payer. Codes reported in REF04-02 must be one of the following:
Code Description
C Crossover
Use when the claim was automatically crossed over from one payer to another.
D Direct Data Entry
Use when the claim was manually entered through a DDE terminal or web portal.
E Electronic Submission
Use when the claim was electronically submitted through a transmission or via upload by web portal.
O Other
Use when the claim was submitted in a different format other than DDE, web portal, electronic or paper.
P Paper
Use when the claim was submitted via paper, including paper claims put through an OCR process by the payer.

Not Used

4-3

128

Reference Identification Qualifier

X 1

2/3

Not Used

4-4

127

Reference Identification

X 1

1/80

Not Used

4-5

128

Reference Identification Qualifier

X 1

2/3

Not Used

4-6

127

Reference Identification

X 1

1/80

REF - CLAIM AUTHORIZATION INFORMATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a specific authorization identifier is applicable to the claim, used in the adjudication process, or is a result of the adjudication process. If not required by this implementation guide, do not send.

TR3 Example:

REF✱BB✱12346789A~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Authorization Number

Use when supplying an authorization number that was assigned during and used by the adjudication process.

Prior Authorization Number

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Claim Authorization Number

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

DTM - STATEMENT DATES

X12 Name:

Date/Time Reference

X12 Purpose:

To specify pertinent dates and times

X12 Syntax:

R020305
At least one of DTM02, DTM03 or DTM05 is required.
C0403
If DTM04 is present, then DTM03 is required.
P0506
If either DTM05 or DTM06 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Service Dates are not supplied at the Service Payment Information Loop, Loop ID 2110, and CLP02 does not equal 25 (Predetermination). If not required by the implementation guide, do not send.

TR3 Notes:

Dates at the claim level apply to the entire claim, including all service lines. Dates at the service line level apply only to the service line where they appear.
When claim dates are not provided, service dates are required for every service line.
When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines.
For retail pharmacy claims, the Claim Statement Period Start Date is equivalent to the prescription filled date.
When payment is being made in advance of services, the use of future dates is allowed.

TR3 Example:

DTM✱233✱20220916~

DTM

✱

✱

✱

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

232

Claim Statement Period Start

233

Claim Statement Period End

Required

373

Date

X 1

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

SEGMENT SYNTAX: R020305

INDUSTRY NAME: Claim Date

If a Claim Statement Period Start (Statement From) date is reported without a Claim Statement Period End (Statement To) date, it is assumed that the Statement From date and Statement To date are the same. If only the Statement To date is reported, the Statement From date is assumed to be different from the Statement To date but not reported at the payer's discretion.

Not Used

337

Time

X 1

4/8

Not Used

623

Time Code

O 1

Not Used

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1251

Date Time Period

X 1

1/35

DTM*036 - COVERAGE EXPIRATION DATE

X12 Name:

Date/Time Reference

X12 Purpose:

To specify pertinent dates and times

X12 Syntax:

R020305
At least one of DTM02, DTM03 or DTM05 is required.
C0403
If DTM04 is present, then DTM03 is required.
P0506
If either DTM05 or DTM06 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when payment is denied because of the expiration of coverage. If not required by this implementation guide, do not send.

TR3 Example:

DTM✱036✱20221001~

DTM

✱

✱

✱

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

036

Expiration

Required

373

Date

X 1

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

SEGMENT SYNTAX: R020305

This is the expiration date of the patient's coverage.

Not Used

337

Time

X 1

4/8

Not Used

623

Time Code

O 1

Not Used

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1251

Date Time Period

X 1

1/35

DTM*050 - CLAIM RECEIVED DATE

X12 Name:

Date/Time Reference

X12 Purpose:

To specify pertinent dates and times

X12 Syntax:

R020305
At least one of DTM02, DTM03 or DTM05 is required.
C0403
If DTM04 is present, then DTM03 is required.
P0506
If either DTM05 or DTM06 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when state or federal regulations or the provider contract mandates interest payment or prompt payment discounts based upon the receipt date of the claim by the payer on non-pharmacy claims.
Or
Required when state or federal regulations or the provider contract mandates interest payment or prompt payment discounts based upon the receipt date of the claim by the payer and the prescription/service date of service is not equal to the claim received date for pharmacy claims.

If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

TR3 Example:

DTM✱050✱20221124~

DTM

✱

✱

✱

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

050

Received

Required

373

Date

X 1

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

SEGMENT SYNTAX: R020305

This is the date that the claim was received by the payer.

Not Used

337

Time

X 1

4/8

Not Used

623

Time Code

O 1

Not Used

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1251

Date Time Period

X 1

1/35

DTM*242 - CLEAN CLAIM DATE

X12 Name:

Date/Time Reference

X12 Purpose:

To specify pertinent dates and times

X12 Syntax:

R020305
At least one of DTM02, DTM03 or DTM05 is required.
C0403
If DTM04 is present, then DTM03 is required.
P0506
If either DTM05 or DTM06 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a clean claim date, as determined by the payer, is different than the claim received date and state/federal requirements (including workers' compensation) or provider contracts utilize the clean claim date for payment decisions. If not required by this implementation guide, do not send.

TR3 Notes:

Examples of use of this segment include complete bill determinations, interest payments or prompt payment discounts.

TR3 Example:

DTM✱242✱20220106~

DTM

✱

✱

✱

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

242

Actual Start

Required

373

Date

X 1

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

SEGMENT SYNTAX: R020305

INDUSTRY NAME: Clean Claim Date

Not Used

337

Time

X 1

4/8

Not Used

623

Time Code

O 1

Not Used

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1251

Date Time Period

X 1

1/35

DTM*439 - CORRECTED ACCIDENT DATE

X12 Name:

Date/Time Reference

X12 Purpose:

To specify pertinent dates and times

X12 Syntax:

R020305
At least one of DTM02, DTM03 or DTM05 is required.
C0403
If DTM04 is present, then DTM03 is required.
P0506
If either DTM05 or DTM06 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the accident date submitted on a property and casualty claim is different from the date on file with the payer. If not required by this implementation guide, do not send.

TR3 Example:

DTM✱439✱20220106~

DTM

✱

✱

✱

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

439

Accident

Required

373

Date

X 1

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

SEGMENT SYNTAX: R020305

INDUSTRY NAME: Corrected Accident Date

Not Used

337

Time

X 1

4/8

Not Used

623

Time Code

O 1

Not Used

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1251

Date Time Period

X 1

1/35

DTM*431 - CORRECTED ONSET OF CURRENT SYMPTOMS OR ILLNESS DATE

X12 Name:

Date/Time Reference

X12 Purpose:

To specify pertinent dates and times

X12 Syntax:

R020305
At least one of DTM02, DTM03 or DTM05 is required.
C0403
If DTM04 is present, then DTM03 is required.
P0506
If either DTM05 or DTM06 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Onset of Current Symptoms or Illness date submitted on a property and casualty claim is different from the date on file with the payer. If not required by this implementation guide, do not send.

TR3 Example:

DTM✱431✱20220106~

DTM

✱

✱

✱

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

431

Onset of Current Symptoms or Illness

Required

373

Date

X 1

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

SEGMENT SYNTAX: R020305

INDUSTRY NAME: Corrected Onset of Current Symptoms or Illness Date

Not Used

337

Time

X 1

4/8

Not Used

623

Time Code

O 1

Not Used

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1251

Date Time Period

X 1

1/35

PER*CX - CLAIM CONTACT INFORMATION

X12 Name:

Administrative Communications Contact

X12 Purpose:

To identify a person or office to whom administrative communications should be directed

X12 Syntax:

P0304
If either PER03 or PER04 is present, then the other is required.
P0506
If either PER05 or PER06 is present, then the other is required.
P0708
If either PER07 or PER08 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when there is a claim specific communications contact. If not required by this implementation guide, do not send.

TR3 Notes:

TR3 Example:

PER✱CX✱JOHN WAYNE✱TE✱8005551212✱EX✱4255~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

366

Contact Function Code

M 1

Code identifying the major duty or responsibility of the person or group named

CODE

DEFINITION

Payers Claim Office

Situational

Name

O 1

1/60

Free-form name

SITUATIONAL RULE: Required when the name of the individual to contact is not already defined or is different than the name within any of the PER02s in the 1000A loop. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Contact Name

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Claim Contact Communications Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when a second communication contact number is needed. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Telephone Extension

Use when reporting a telephone extension for the preceding telephone number.

Facsimile

Telephone

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when PER05 is used. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Contact Communications Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when an extension applies to the previous communication contact number (PER06). If not required by this implementation guide, do not send.

CODE

DEFINITION

Telephone Extension

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when an extension applies to the previous communications contact number (PER06). If not required by this implementation guide, do not send.

INDUSTRY NAME: Communication Number Extension

Not Used

443

Contact Inquiry Reference

O 1

1/20

PER - ENTITY SELF-INSURED PLAN / JURISDICTION CONTACT

X12 Name:

Administrative Communications Contact

X12 Purpose:

To identify a person or office to whom administrative communications should be directed

X12 Syntax:

P0304
If either PER03 or PER04 is present, then the other is required.
P0506
If either PER05 or PER06 is present, then the other is required.
P0708
If either PER07 or PER08 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the patient/insured is a member in a self-insured plan that is different than the payer identified in loop 1000A.
OR
Required when a payer has reported a jurisdiction/payer remittance information statement identification number in loop 2100 REF Other Claim Related Identification, REF01 value "OX", on a workers' compensation claim.

If not required by this implementation guide, do not send.

TR3 Notes:

Entity Self-Insured Plan
This information identifies the contact to discuss ERISA coverage issues, extending coverage request and/or obtaining payment for services not covered by the Benefit Plan; for example, experimental/investigation procedures.

The Jurisdiction/Payer Remittance Information Statement identifies the unsecure public jurisdiction/payer website URL location where the provider can access the full text description of the jurisdiction/payer remittance information statement.
When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as 1, in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension, do not include data that indicates an extension, such as "ext" or "x-".

TR3 Example:

PER✱AF✱JOHN DOE✱TE✱3035551212~PER✱IC✱JURISDICTION PAYER✱UR✱www.payer.com/jurisdictionpolicies.html~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

366

Contact Function Code

M 1

Code identifying the major duty or responsibility of the person or group named

CODE

DEFINITION

Authorized Financial Contact

Use when reporting the Entity Self-Insured Plan contact information.

Information Contact

Use when reporting the jurisdiction/payer name.

Situational

Name

O 1

1/60

Free-form name

SITUATIONAL RULE: Required when the name of the self-insured plan to contact is not already defined or is different than the payer in loop 1000AORthe jurisdiction is not already defined or is different than the payer in REF - Other Claim Related information in loop 2100.If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Contact Name

If the PER01 value is 'AF' then this is the Entity Self-Insured Plan contact name.

If PER01 value is 'IC' then this is the jurisdiction/payer name.

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

If the PER01 value is 'IC' then the only PER03 qualifier that can be used is 'UR'.

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

Uniform Resource Locator (URL)

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Claim Contact Communications Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when PER01 is 'AF' and a second communication contact number is needed. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Telephone Extension

Use when reporting a telephone extension for the preceding telephone number.

Facsimile

Telephone

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when PER01 is 'AF' and a second communication contact number is needed. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Contact Communications Number

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when an extension applies to the previous communication contact number (PER06). If not required by this implementation guide, do not send.

CODE

DEFINITION

Telephone Extension

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when an extension applies to the previous communications contact number (PER06). If not required by this implementation guide, do not send.

INDUSTRY NAME: Communication Number Extension

Not Used

443

Contact Inquiry Reference

O 1

1/20

PER*CN - WORKERS' COMPENSATION PAYER WEBSITE

X12 Name:

Administrative Communications Contact

X12 Purpose:

To identify a person or office to whom administrative communications should be directed

X12 Syntax:

P0304
If either PER03 or PER04 is present, then the other is required.
P0506
If either PER05 or PER06 is present, then the other is required.
P0708
If either PER07 or PER08 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a workers' compensation payer has reported a jurisdiction rule/statute identification number in loop 2100 Other Claim Payment Identification REF Segment REF01 with a value of '5N'. If not required by this implementation guide, do not send.

TR3 Notes:

This information identifies the public jurisdiction/payer website URL location (secured or unsecured) where the provider can access the full text description of the jurisdiction rule/statute that was used for the denial or adjustment of a claim. Used for workers' compensation only.

TR3 Example:

PER✱CN✱JURISDICTION PAYER✱UR✱www.payer.com/jurisdictionpolicies.html~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

366

Contact Function Code

M 1

Code identifying the major duty or responsibility of the person or group named

CODE

DEFINITION

General Contact

Required

Name

O 1

1/60

Free-form name

INDUSTRY NAME: Jurisdiction Name

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Uniform Resource Locator (URL)

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Jurisdiction/Payer Website URL

Not Used

365

Communication Number Qualifier

X 1

Not Used

364

Communication Number

X 1

1/2048

Not Used

365

Communication Number Qualifier

X 1

Not Used

364

Communication Number

X 1

1/2048

Not Used

443

Contact Inquiry Reference

O 1

1/20

AMT*B6 - CLAIM ALLOWED AMOUNT

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Used to report this payer's allowed amount that was used in adjudicating the claim, prior to considering patient responsibility. See section 1.10.2.13 for information on Secondary Payment Reporting. Report the amount, even when zero (0). This must be equal to the sum of the allowed amounts at the service line (Loop 2110, AMT01=B6). This segment is used to convey information only. It is not part of the financial balancing of the 835.

TR3 Example:

AMT✱B6✱425~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code specifying the amount qualifier

CODE

DEFINITION

Allowed - Actual

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Claim Allowed Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Not Used

478

Credit/Debit Flag Code

O 1

AMT - CLAIM SUPPLEMENTAL INFORMATION

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment to convey information only. It is not part of the financial balancing of the 835.
Send/receive one AMT for each applicable non-zero value. Do not report any zero values.
Supplemental information reported at the Service level (2110 loop) AMT Segment is not repeated at the claim level (2100 loop) AMT Segment.

TR3 Example:

AMT✱T✱45~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code specifying the amount qualifier

CODE

DEFINITION

Coverage Amount

Use when reporting the total covered charges. This is not used for the allowed amount.

Discount Amount

Use when reporting a Prompt Pay Discount Amount. See Section 1.10.2.9 (Interest and Prompt Payment Discounts) for additional information.

Per Day Limit

Patient Amount Paid

Use when reporting the amount the patient has already paid.

Interest

See section 1.10.2.9 (Interest and Prompt Payment Discounts) for additional information.

Negative Ledger Balance

Use when the payer is Medicare Part A or Medicare Part B and reporting a Negative Ledger Balance.

Tax

Federal Medicare or Medicaid Payment Mandate - Category 1

Federal Medicare or Medicaid Payment Mandate - Category 2

Federal Medicare or Medicaid Payment Mandate - Category 3

Federal Medicare or Medicaid Payment Mandate - Category 4

Federal Medicare or Medicaid Payment Mandate - Category 5

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Claim Supplemental Information Amount

Refer to Appendix B.1.1.3 for more information about decimal data elements.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Not Used

478

Credit/Debit Flag Code

O 1

QTY - CLAIM SUPPLEMENTAL INFORMATION QUANTITY

X12 Name:

Quantity Information

X12 Purpose:

To specify quantity information

X12 Syntax:

R0204
At least one of QTY02 or QTY04 is required.
E0204
Only one of QTY02 or QTY04 may be present.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the value of a specific quantity identified by the QTY01 qualifier is non-zero. If not required by this implementation guide, do not send.

TR3 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.

TR3 Example:

QTY✱ZK✱3~

QTY

✱

✱

✱

Composite
Unit of Mea

✱

Required

673

Quantity Qualifier

M 1

Code specifying the type of quantity

CODE

DEFINITION

Covered - Actual

Co-insured - Actual

Life-time Reserve - Actual

Life-time Reserve - Estimated

Non-Covered - Estimated

Not Replaced Blood Units

Outlier Days

Prescription

Use when reporting the number of prescriptions for the patient on an inpatient claim when known by the payer.

Visits

Use when the inpatient visit count is greater than 1.

Federal Medicare or Medicaid Payment Mandate - Category 1

Federal Medicare or Medicaid Payment Mandate - Category 2

Federal Medicare or Medicaid Payment Mandate - Category 3

Federal Medicare or Medicaid Payment Mandate - Category 4

Federal Medicare or Medicaid Payment Mandate - Category 5

Required

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: R0204, E0204

INDUSTRY NAME: Claim Supplemental Information Quantity

Not Used

C001

Composite Unit of Measure

O 1

Not Used

Free-form Information

X 1

1/30

LQ - HEALTH CARE REMARK CODES

X12 Name:

Industry Code Identification

X12 Purpose:

To identify standard industry codes

X12 Syntax:

C0102
If LQ01 is present, then LQ02 is required.

Loop:

Loop 2105 - CORRECTED PRIORITY PAYER NAME

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when remark codes are necessary for the provider to fully understand the adjudication message for the claim. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

TR3 Notes:

Remark codes reported in the LQ segment have no direct relationship to any Claim Adjustment Reason Code reported in a RAS segment. These remark codes stand alone and provide a message related to the claim as a whole. See section 1.10.2.4 for additional information.

TR3 Example:

LQ✱HE✱MA15~

✱

✱

Required

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

SEGMENT SYNTAX: C0102

CODE

DEFINITION

Remittance Advice Remark Code

CODE SOURCE: 411: Remittance Advice Remark Code

Insurance Industry Specific Remark Codes

CODE SOURCE: 973: Insurance Industry Specific Remark Codes

National Council for Prescription Drug Programs Reject Codes

CODE SOURCE: 530: National Council for Prescription Drug Programs Reject Codes

Required

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

SEGMENT SYNTAX: C0102

INDUSTRY NAME: Remark Code

N1*COR - CORRECTED PRIORITY PAYER NAME

X12 Name:

Party Identification

X12 Purpose:

To identify a party by type of organization, name, and code

X12 Syntax:

R0203
At least one of N102 or N103 is required.
P0304
If either N103 or N104 is present, then the other is required.
C0703
If N107 is present, then N103 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the payer's (identified in loop 1000A) records indicate that another payer has responsibility for processing of the claim, and the claim is not being automatically transferred to that payer.

TR3 Example:

N1✱COR✱NATIONAL INSURANCE COMPANY✱XV✱7777777777~

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

COR

Corrected Name

Required

Name

X 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Corrected Priority Payer Name

Situational

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: R0203, P0304, C0703

SITUATIONAL RULE: Required when N104 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Standard Unique Health Plan Identifier (HPID)

Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

CODE SOURCE: 540: Health Plan Identifier (HPID)

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when reporting Health Plan Identifier (HPID) or Other Entity Identifier (OEID).If not required by this implementation guide, do not send.

INDUSTRY NAME: Corrected Priority Payer Identification Number

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

C076

Composite Identification Codes

O 1

NM1*GB - OTHER SUBSCRIBER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop 2105 - CORRECTED PRIORITY PAYER NAME

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a corrected priority payer has been identified in this iteration of Loop 2105 N1 Corrected Priority Payer Name Segment AND the name or ID of the other subscriber for this payer is known. If not required by this implementation guide, do not send.

TR3 Notes:

This is the name and ID number of the other subscriber when a corrected priority payer has been identified. When used, either the name or ID must be supplied.

TR3 Example:

NM1✱GB✱1✱SMITH✱JANE~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Other Insured

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when known or when NM109 is not present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Subscriber Last Name

At least one of NM103 or NM109 must be present.

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the Other Subscriber is a person (NM102=1), NM103 is present and the first name is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Subscriber First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when the Other Subscriber is a person (NM102=1), NM103 is present and the Middle Name or Initial is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Subscriber Middle Name or Initial

If this data element is used and contains only one character, it is assumed to represent the middle initial.

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when the Other Subscriber is a person (NM102=1), the information is known and this information is necessary for identification of the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Subscriber Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when NM109 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Federal Taxpayer's Identification Number

Use when NM102 = 2 and the Federal Taxpayer's Identifier is the primary identifier.

Member Identification Number

Use when indicating the subscriber's identification number as assigned by the payer. (For example, Insureds ID, Subscribers ID, Health Insurance Claim Number (HIC), etc.).

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when known or when NM103 is not present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Other Subscriber Identifier

At least one of NM103 or NM109 must be present.

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

SVC - SERVICE PAYMENT INFORMATION

X12 Name:

Service Information

X12 Purpose:

To supply payment and control information to a provider for a particular service

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required for all service lines in a
- professional claim or
- dental claim or
- institutional claim priced at the service line level

OR

Required when payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem).

OR

In the case of pharmacy claims, refer to the NCPDP X12N 835 Payment Reference Guide.
If not required by this implementation guide, do not send.

TR3 Notes:

The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level RAS adjustment to the per diem is appropriate (e.g., RAS*25*CO*78~) and may be sent at the sender's discretion rather than including every service line. See sections 1.10.2.4.1 and 1.10.2.4.6 for additional information.
See section 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information.

TR3 Example:

SVC✱HC:99214✱100✱80✱✱1~SVC✱HC:99214✱100✱80✱✱1✱RA:992~SVC✱RA:00000✱100✱0✱✱1~SVC✱HC:26010:F5✱100✱80✱✱1✱RA:26010:5~

SVC

✱

C003

Comp. Med.
Proced. ID

✱

✱

✱

✱

✱

Comp. Med.
Proced. ID

✱

Required

C003

Composite Medical Procedure Identifier

M 1

To identify a medical procedure by its standardized codes and applicable modifiers

SEMANTIC: SVC01 is the medical procedure upon which adjudication is based.

COMMENT: For Medicare Part A claims, SVC01 would be the Healthcare Common Procedure Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132).

X12 COMPOSITE SEMANTIC NOTES:

C003-01 qualifies C003-02 and C003-08.
If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
C003-03 modifies the value in C003-02 and C003-08.
C003-04 modifies the value in C003-02 and C003-08.
C003-05 modifies the value in C003-02 and C003-08.
C003-06 modifies the value in C003-02 and C003-08.
C003-07 is the description of the procedure identified in C003-02.
C003-08 represents the ending value in the range in which the code occurs.
C003-09 modifies the value in C003-02 and C003-08.
C003-10 modifies the value in C003-02 and C003-08.
C003-11 modifies the value in C003-02 and C003-08.
C003-12 modifies the value in C003-02 and C003-08.

This is the adjudicated medical procedure information.
This code is a composite data structure.
SVC01-02 through SVC01-06 and SVC01-09 through SVC01-12 are not intended to be validated against any code list when the qualifier in SVC01-01 is RA as they reference invalid or unrecognized codes.

Required

1-1

235

Product/Service ID Qualifier

M 1

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

INDUSTRY NAME: Product or Service ID Qualifier

The value in SVC01-01 qualifies the value in SVC01-02, SVC01-04, SVC01-05, SVC01-06, SVC01-09, SVC01-10, SVC01-11, SVC01-12.

CODE

DEFINITION

American Dental Association Codes

CODE SOURCE: 135: American Dental Association

Jurisdiction Specific Procedure and Supply Codes

CODE SOURCE: 576: Workers Compensation Specific Procedure and Supply Codes

Healthcare Common Procedure Coding System (HCPCS) Codes

Use when reporting HCPCS or CPT codes. AMA's CPT codes are level 1 HCPCS codes.

CODE SOURCE: 130: Healthcare Common Procedure Coding System

Health Insurance Prospective Payment System (HIPPS) Rate Code

Use when reporting the Skilled Nursing Facility Group Rate Code or the Home Health Agency Outpatient Prospective Payment System Rate Code.

CODE SOURCE: 716: Health Insurance Prospective Payment System (HIPPS) Rate Code

National Drug Code in 5-4-2 Format

CODE SOURCE: 240: National Drug Code by Format

National Uniform Billing Committee (NUBC) UB92 Codes

CODE SOURCE: 132: National Uniform Billing Committee (NUBC) Codes

Return Code

Use when an invalid or unrecognized code was submitted on the claim and used for adjudication. Refer to section 1.10.2.14.1 for information on reporting invalid or unrecognized procedure information.

Mutually Defined

Use when reporting the Device Identifier of Unique Device Identifier.

Prior to the mandated implementation date for the Unique Device Identifier, willing trading partners may agree to follow an early implementation approach.

Code Source: FDA Global Unique Device Identifier Database (GUDID) http://accessgudid.nlm.nih.gov/
Available from:
National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894

Required

1-2

234

Product/Service ID

M 1

1/80

Identifying number for a product or service

INDUSTRY NAME: Adjudicated Procedure Code

This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-01.

Situational

1-3

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when a procedure code modifier applies to this service. If not required by this implementation guide, do not send.

Situational

1-4

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when a second procedure code modifier applies to this service. If not required by this implementation guide, do not send.

Situational

1-5

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when a third procedure code modifier applies to this service. If not required by this implementation guide, do not send.

Situational

1-6

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when a fourth procedure code modifier applies to this service. If not required by this implementation guide, do not send.

Not Used

1-7

352

Description

O 1

1/80

Not Used

1-8

234

Product/Service ID

O 1

1/80

Situational

1-9

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when a fifth procedure code modifier applies to this service. If not required by this implementation guide, do not send.

Situational

1-10

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when a sixth procedure code modifier applies to this service. If not required by this implementation guide, do not send.

Situational

1-11

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when a seventh procedure code modifier applies to this service. If not required by this implementation guide, do not send.

Situational

1-12

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when an eighth procedure code modifier applies to this service. If not required by this implementation guide, do not send.

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SVC02 is the submitted service charge.

INDUSTRY NAME: Line Item Charge Amount

Use this monetary amount for the submitted service charge amount.
Refer to Appendix B.1.1.3 for more information about decimal data elements.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.
See section 1.10.2.14.2 for usage information when service lines are split.

Required

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: SVC03 is the amount paid this service.

INDUSTRY NAME: Line Item Provider Payment Amount

Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent RAS segments of this loop. See 1.10.2.1, Financial Balancing, for additional information.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

234

Product/Service ID

O 1

1/80

Identifying number for a product or service

SEMANTIC: SVC04 is the National Uniform Billing Committee Revenue Code.

SITUATIONAL RULE: Required when an NUBC revenue code was considered during adjudication in addition to a procedure code already identified in SVC01. If not required by this implementation guide, do not send.

INDUSTRY NAME: National Uniform Billing Committee Revenue Code

This element is not used when the original claim and adjudication only reference an NUBC revenue code. In that situation, the NUBC Revenue Code is supplied in SVC01.

Required

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SVC05 is the paid units of service.

INDUSTRY NAME: Units of Service Paid Count

See Section 1.10.2.4.2 Claim/Service Adjustment Information Segment for Units of Service balancing requirements.

Situational

C003

Composite Medical Procedure Identifier

O 1

To identify a medical procedure by its standardized codes and applicable modifiers

SEMANTIC: SVC06 is the original submitted medical procedure.

X12 COMPOSITE SEMANTIC NOTES:

C003-01 qualifies C003-02 and C003-08.
If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
C003-03 modifies the value in C003-02 and C003-08.
C003-04 modifies the value in C003-02 and C003-08.
C003-05 modifies the value in C003-02 and C003-08.
C003-06 modifies the value in C003-02 and C003-08.
C003-07 is the description of the procedure identified in C003-02.
C003-08 represents the ending value in the range in which the code occurs.
C003-09 modifies the value in C003-02 and C003-08.
C003-10 modifies the value in C003-02 and C003-08.
C003-11 modifies the value in C003-02 and C003-08.
C003-12 modifies the value in C003-02 and C003-08.

SITUATIONAL RULE: Required when the adjudicated procedure code and/or modifier code(s) / modifier order provided in SVC01 is different from the submitted procedure code and/or modifier code(s) / modifier order from the claim. If not required by this implementation guide, do not send.

This code is a composite data structure.
This is the Submitted Procedure Code information.
SVC06-02 through SVC06-06 and SVC06-09 through SVC06-12 are intended to convey the originally submitted service, and are not intended to be validated when the qualifier in SVC06-01 is RA.

Required

6-1

235

Product/Service ID Qualifier

M 1

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

INDUSTRY NAME: Product or Service ID Qualifier

The value in SVC06-01 qualifies the value in SVC06-02, SVC06-04, SVC06-05, SVC06-06, SVC06-07, SVC06-09, SVC06-10, SVC06-11, SVC06-12.

CODE

DEFINITION

American Dental Association Codes

CODE SOURCE: 135: American Dental Association

Jurisdiction Specific Procedure and Supply Codes

CODE SOURCE: 576: Workers Compensation Specific Procedure and Supply Codes

Healthcare Common Procedure Coding System (HCPCS) Codes

Use when reporting HCPCS or CPT codes. AMA's CPT codes are level 1 HCPCS codes.

CODE SOURCE: 130: Healthcare Common Procedure Coding System

Health Insurance Prospective Payment System (HIPPS) Rate Code

Use when reporting the Skilled Nursing Facility Group Rate Code or the Home Health Agency Outpatient Prospective Payment System Rate Code.

CODE SOURCE: 716: Health Insurance Prospective Payment System (HIPPS) Rate Code

National Drug Code in 5-4-2 Format

CODE SOURCE: 240: National Drug Code by Format

National Uniform Billing Committee (NUBC) UB92 Codes

CODE SOURCE: 132: National Uniform Billing Committee (NUBC) Codes

Return Code

Use when an invalid or unrecognized procedure code was submitted on the claim. Refer to section 1.10.2.14.1 for information on reporting invalid or unrecognized procedure information.

Mutually Defined

Required

6-2

234

Product/Service ID

M 1

1/80

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

Situational

6-3

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when a procedure code modifier applies to this service. If not required by this implementation guide, do not send.

Situational

6-4

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when a second procedure code modifier applies to this service. If not required by this implementation guide, do not send.

Situational

6-5

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when a third procedure code modifier applies to this service. If not required by this implementation guide, do not send.

Situational

6-6

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when a fourth procedure code modifier applies to this service. If not required by this implementation guide, do not send.

Situational

6-7

352

Description

O 1

1/80

A free-form description to clarify the related data elements and their content

SITUATIONAL RULE: Required when a description was received on the original service for a not otherwise classified procedure code. If not required by this implementation guide, do not send.

INDUSTRY NAME: Procedure Code Description

Not Used

6-8

234

Product/Service ID

O 1

1/80

Situational

6-9

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when a fifth procedure code modifier applies to this service. If not required by this implementation guide, do not send.

Situational

6-10

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when a sixth procedure code modifier applies to this service. If not required by this implementation guide, do not send.

Situational

6-11

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when a seventh procedure code modifier applies to this service. If not required by this implementation guide, do not send.

Situational

6-12

1339

Procedure Modifier

O 1

This identifies special circumstances related to the performance of the service, as defined by trading partners

SITUATIONAL RULE: Required when an eighth procedure code modifier applies to this service. If not required by this implementation guide, do not send.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SVC07 is the original submitted units of service.

SITUATIONAL RULE: Required when the paid units of service provided in SVC05 is different from the submitted units of service from the original claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Original Units of Service Count

See Section 1.10.2.4.2 Claim/Service Adjustment Information Segment for Units of Service balancing requirements.
See section 1.10.2.14.2 for usage information when service lines are split.

DTM - SERVICE DATE

X12 Name:

Date/Time Reference

X12 Purpose:

To specify pertinent dates and times

X12 Syntax:

R020305
At least one of DTM02, DTM03 or DTM05 is required.
C0403
If DTM04 is present, then DTM03 is required.
P0506
If either DTM05 or DTM06 is present, then the other is required.

X12 Set Notes:

NOTE: The DTM segment in the SVC loop is to be used to express dates and date ranges specifically related to the service identified in the SVC segment.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when Loop ID 2100 Claim Statement Period Start or Claim Statement Period End are not supplied, or the service dates are not the same as reported at the claim level, and CLP02 does not equal 25 (Predetermination). If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

TR3 Notes:

Dates at the service line level apply only to the service line where they appear.
If used for inpatient claims and no service date was provided on the claim then report the through date from the claim level.
When claim dates are not provided, service dates are required for every service line.
When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines.
For retail pharmacy claims, the service date is equivalent to the prescription filled date.
For predetermination claims when the CLP02 value is 25 - Predetermination Pricing Only - No Payment, no dates are supported at either claim or service level.
When payment is being made in advance of services, the use of future dates is allowed.

TR3 Example:

DTM✱472✱20221031~

DTM

✱

✱

✱

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

150

Service Period Start

Use when reporting the beginning of multi-day services. When used, an additional DTM with qualifier 151 must be sent, and the dates in each cannot be the same.

151

Service Period End

Use when reporting the end of multi-day services. When used, an additional DTM with qualifier 150 must be sent, and the dates in each cannot be the same.

472

Service

Use when reporting a single day service. When used, no additional DTMs are allowed for this service.

Required

373

Date

X 1

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

SEGMENT SYNTAX: R020305

INDUSTRY NAME: Service Date

Not Used

337

Time

X 1

4/8

Not Used

623

Time Code

O 1

Not Used

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1251

Date Time Period

X 1

1/35

RAS - SERVICE ADJUSTMENT INFORMATION

X12 Name:

Reason Adjustment

X12 Purpose:

To supply Claim Adjustment Reason Codes and amounts as needed for an entire claim or for a particular service within the claim being paid

X12 Comments:

Adjustment information is intended to help the provider balance the remittance information. Adjustment amounts must fully explain the difference between submitted charges and the amount paid.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02). If not required by this implementation guide, do not send.

TR3 Notes:

Payers must use this RAS segment to report service level adjustments that cause the amount paid to differ from the amount originally charged. See 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information.
An example of this level of RAS is the reduction for the part of the service charge that exceeds the usual and customary charge for the service. See sections 1.10.2.1, Financial Balancing, and 1.10.2.4, Claim Adjustment Information and Service Adjustment Information Segment Theory, for additional information.

TR3 Example:

RAS

✱

✱

Claim Adjst
Group Code

✱

✱

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: RAS01 is the amount of adjustment.

INDUSTRY NAME: Adjustment Amount

Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03. This amount must not be zero (0).
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Required

1785

Claim Adjustment Group Code

M 1

1/10

Code identifying the general category of payment adjustment.

Evaluate the usage of group codes in RAS02 based on the following order for their applicability to a set of one or more adjustments: Patient Responsibility, Contractual Obligation, Payer Initiated, Other Adjustments. (Note: This does not mean that the adjustments must be reported in this order.)

See Front Matter Section 1.10.2.4.5, Claim Adjustment Group Code Usage, for additional information.

CODE SOURCE 974: Claim Adjustment Group Codes

Required

C058

Adjustment Reason

M 15

To provide a reason and related explanation for a Health Care Claim or Service change in payment versus the original submitted charges

SEMANTIC: Position of data in the repeating composite data element conveys no significance.

X12 COMPOSITE SYNTAX NOTES:

P0203
If either C05802 or C05803 is present, then the other is required.
C0403
If C05804 is present, then C05803 is required.
C0504
If C05805 is present, then C05804 is required.
C0605
If C05806 is present, then C05805 is required.
C0706
If C05807 is present, then C05806 is required.

X12 COMPOSITE SEMANTIC NOTES: C05802 qualifies C05803, C05804, C05805, C05806 and C05807.

This composite identifies the reason for the adjustment of the dollar amount identified in RAS01.
More than one iteration of this composite may be provided only when the entire service submitted charge (SVC02) is being adjusted by this RAS segment (RAS01 equals SVC02) and there are multiple adjustment reasons that are each applicable to the full amount in RAS01.

See 1.10.2.4.2 Claim/Service Adjustment Information Segment for additional information.

Required

3-1

1034

Claim Adjustment Reason Code

M 1

1/5

Code identifying the detailed reason the adjustment was made

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

Situational

3-2

1270

Code List Qualifier Code

X 1

1/3

Code identifying a specific industry code list

COMPOSITE SYNTAX: P0203

SITUATIONAL RULE: Required when a remark code or National Council for Prescription Drug Programs Reject Code is necessary for the provider to fully understand the adjustment message for the service adjustment reason identified in RAS03-01. If not required by this implementation guide, do not send.

CODE

DEFINITION

Remittance Advice Remark Code

CODE SOURCE: 411: Remittance Advice Remark Code

Insurance Industry Specific Remark Codes

CODE SOURCE: 973: Insurance Industry Specific Remark Codes

National Council for Prescription Drug Programs Reject Codes

CODE SOURCE: 530: National Council for Prescription Drug Programs Reject Codes

Situational

3-3

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: P0203, C0403

INDUSTRY NAME: Remark Code

Remark codes that include "Alert" in their description are not reported in the RAS segment, but in the LQ segment at the appropriate level.

Situational

3-4

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: C0403, C0504

SITUATIONAL RULE: Required when an additional remark code or National Council for Prescription Drug Programs Reject Code is necessary for the provider to fully understand the adjustment message for the service adjustment reason identified in RAS03-01. If not required by this implementation guide, do not send.

INDUSTRY NAME: Remark Code

Remark codes that include "Alert" in their description are not reported in the RAS segment, but in the LQ segment at the appropriate level.

Situational

3-5

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: C0504, C0605

INDUSTRY NAME: Remark Code

Remark codes that include "Alert" in their description are not reported in the RAS segment, but in the LQ segment at the appropriate level.

Situational

3-6

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: C0605, C0706

INDUSTRY NAME: Remark Code

Remark codes that include "Alert" in their description are not reported in the RAS segment, but in the LQ segment at the appropriate level.

Situational

3-7

1271

Industry Code

O 1

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: C0706

INDUSTRY NAME: Remark Code

Remark codes that include "Alert" in their description are not reported in the RAS segment, but in the LQ segment at the appropriate level.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: RAS04 is the units of service being adjusted.

SITUATIONAL RULE: Required when units of service are being adjusted. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

A positive value decreases the quantity, and a negative value increases the quantity.
See section 1.10.2.4.2 for information about quantity balancing.

REF - SERVICE IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specific reference identifiers are applicable to the claim, used in the adjudication process, or a result of the adjudication process. If not required by this implementation guide, do not send.

TR3 Example:

REF✱E9✱12346789A~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Attachment Code

Use when an Attachment Control Number was assigned by the provider.

Location Number

Use when the specific site of service affected the payment of the claim.

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Service Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF - PAYMENT DETERMINATION METHODOLOGY

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required for non-pharmacy claims when specific reference identifiers are applicable to the service line, used in the adjudication process, or is a result of the adjudication process. If not required by this implementation guide, do not send.

TR3 Example:

REF✱9V✱TSUR~REF✱APC✱6541~REF✱AFT✱033214~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Ambulatory Patient Group (APG) Number

Payment Category

AFT

Fee Schedule Identifier

APC

Ambulatory Payment Classification

CODE SOURCE: 468: Ambulatory Payment Classification

Rate code number

Use when reporting the Ambulatory Surgical Center (ASC) rate for Medicare, either 0, 50, 100 or 150%.

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Service Reference Identifier

This is the 'Payment Determination Methodology' identified by the REF01 qualifier used to adjudicate and derive the allowed amount for the service.
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*6R - LINE ITEM CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a Line Item Control Number was received on the original claim or when claim or service line splitting has occurred. If not required by this implementation guide, do not send.

TR3 Notes:

This is the Line Item Control Number submitted on the 837, or Line Item Sequence Number when no Line Item Control Number was submitted. This is utilized by the provider for tracking.

TR3 Example:

REF✱6R✱54321~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Control Number

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Line Item Control Number

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF - SERVICE PROVIDER INFORMATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the service provider for this service is different than the service provider applicable at the claim level. If not required by this implementation guide, do not send.

TR3 Example:

REF✱HPI✱1234567891~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Provider Identifier

Use when reporting a proprietary provider number assigned by the payer identified in the payer name loop (1000A) associated with this claim. This is true regardless of whether the payer is Medicare, Medicaid, a Blue Cross Blue Shield plan, a Commercial plan, or any other health plan.

HPI

Standard Unique Health Identifier for Health Care Providers (NPI)

Use when the provider is a covered entity under the mandate and must enumerate.

CODE SOURCE: 537: National Provider Identifier (NPI)

Federal Taxpayer's Identification Number

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Rendering Provider Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*0K - HEALTHCARE POLICY IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the payment is adjusted in accordance with the Payer's published Healthcare Policy Code list
AND
A Claim Adjustment Reason Code identified by the notation, "refer to 835 Healthcare Policy identification segment", in the Claim Adjustment Reason Code List is present in a related RAS segment
AND
The payer has a published enumerated healthcare policy code list available to healthcare providers via a secured or unsecured public website

If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

TR3 Notes:

Healthcare Policy - A clinical/statutory rule used to determine claim adjudication that cannot be explained by the sole use of a claim adjustment reason code in the RAS segment and Remark Code when appropriate.
The term Healthcare Policy is intended to include Medical Review Policy, Dental Policy Review, Property & Casualty Policies, Workers' Comp Policies and Pharmacy Policies; for example, Medicare LMRP's. (Local Medicare Review Policies) and NCD (National Coverage Determinations).
This policy segment must not be used to provide a proprietary explanation code or reason for adjustment.
Supply the Healthcare policy identifier in REF02 as provided by the payer's published Healthcare policy code list. This identifier will be used to access the Healthcare policy associated with the adjudication decision.
If this segment is used, the PER 1000A Payer Website segment is required to provide a WEB contact point (secured or unsecured) where the provider can access the payer's enumerated, published healthcare policy.
When reversing a claim that was originally reported with a Health Care Policy ID it is not necessary to mirror the original Health Care Policy ID REF segment in the reversal. If a policy changes which does not affect the financial adjudication of a claim, it is not necessary to create a reversal and send a correction.

TR3 Example:

REF✱0K✱L12345678910~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Policy Form Identifying Number

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Healthcare Policy Identification

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF - SERVICE AUTHORIZATION INFORMATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a specific reference identifier is applicable to the service line, used in the adjudication process, or is a result of the adjudication process. If not required by this implementation guide, do not send.

TR3 Example:

REF✱BB✱12346789A~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Authorization Number

Use when supplying an authorization number that was assigned during and used by the adjudication process.

Prior Authorization Number

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Service Line Authorization Number

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

AMT*B6 - SERVICE ALLOWED AMOUNT

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Used to report this payer's allowed amount that was used in adjudicating the claim, prior to considering patient responsibility. See section 1.10.2.13 for information on Secondary Payment Reporting. Used to report this payer's allowed amount prior to considering patient responsibility. Report the amount, even when zero (0). The sum of the allowed amounts at the service line must be reported at the claim level (Loop 2100, AMT01=B6). This segment is used to convey information only. It is not part of the financial balancing of the 835.

TR3 Example:

AMT✱B6✱425~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code specifying the amount qualifier

CODE

DEFINITION

Allowed - Actual

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Service Allowed Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Not Used

478

Credit/Debit Flag Code

O 1

AMT - SERVICE SUPPLEMENTAL AMOUNT

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send.

TR3 Notes:

This segment is used to convey information only. It is not part of the financial balancing of the 835.
Supplemental information reported at the Claim level (2100 loop) AMT Segment is not repeated.

TR3 Example:

AMT✱T✱425~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code specifying the amount qualifier

CODE

DEFINITION

Deduction Amount

Use when reporting a Late Filing Reduction.

Tax

Federal Medicare or Medicaid Payment Mandate - Category 1

Federal Medicare or Medicaid Payment Mandate - Category 2

Federal Medicare or Medicaid Payment Mandate - Category 3

Federal Medicare or Medicaid Payment Mandate - Category 4

Federal Medicare or Medicaid Payment Mandate - Category 5

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Service Supplemental Amount

Refer to Appendix B.1.1.3 for more information about decimal data elements.
Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Not Used

478

Credit/Debit Flag Code

O 1

QTY - SERVICE SUPPLEMENTAL QUANTITY

X12 Name:

Quantity Information

X12 Purpose:

To specify quantity information

X12 Syntax:

R0204
At least one of QTY02 or QTY04 is required.
E0204
Only one of QTY02 or QTY04 may be present.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when new Federal Medicare or Medicaid mandates require Quantity counts and value of specific quantities identified in the QTY01 qualifier are non-zero. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment to convey information only. It is not part of the financial balancing of the 835.

TR3 Example:

QTY✱ZK✱3~

QTY

✱

✱

✱

Composite
Unit of Mea

✱

Required

673

Quantity Qualifier

M 1

Code specifying the type of quantity

CODE

DEFINITION

Federal Medicare or Medicaid Payment Mandate - Category 1

Federal Medicare or Medicaid Payment Mandate - Category 2

Federal Medicare or Medicaid Payment Mandate - Category 3

Federal Medicare or Medicaid Payment Mandate - Category 4

Federal Medicare or Medicaid Payment Mandate - Category 5

Required

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: R0204, E0204

INDUSTRY NAME: Service Supplemental Quantity Count

Not Used

C001

Composite Unit of Measure

O 1

Not Used

Free-form Information

X 1

1/30

LQ - HEALTH CARE REMARK CODES

X12 Name:

Industry Code Identification

X12 Purpose:

To identify standard industry codes

X12 Syntax:

C0102
If LQ01 is present, then LQ02 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when Remark Codes or NCPDP Reject Codes not associated directly with a Claim Adjustment Reason Code in a Service Adjustment Information (RAS) segment are necessary for the provider to fully understand the adjudication message for a given service line. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

TR3 Notes:

Remark codes reported in the LQ segment have no direct relationship to any Claim Adjustment Reason Code reported in a RAS segment. These remark codes stand alone and provide a message related to the service as a whole. See section 1.10.2.4 for additional information.

TR3 Example:

LQ✱HE✱MA15~

✱

✱

Required

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

SEGMENT SYNTAX: C0102

CODE

DEFINITION

Remittance Advice Remark Code

CODE SOURCE: 411: Remittance Advice Remark Code

Insurance Industry Specific Remark Codes

CODE SOURCE: 973: Insurance Industry Specific Remark Codes

National Council for Prescription Drug Programs Reject Codes

CODE SOURCE: 530: National Council for Prescription Drug Programs Reject Codes

Required

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

SEGMENT SYNTAX: C0102

INDUSTRY NAME: Remark Code

TOO - TOOTH INFORMATION

X12 Name:

Tooth Identification

X12 Purpose:

To identify a tooth by number and, if applicable, one or more tooth surfaces

X12 Syntax:

P0102
If either TOO01 or TOO02 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a tooth number, tooth surface, or oral cavity area was used in the adjudication of the service or when a tooth number, tooth surface, or oral cavity area was submitted on the service line. If not required by this implementation guide, do not send.

TR3 Example:

TOO✱JP✱12✱L:O~
TOO✱JO✱10~

TOO

✱

✱

✱

Required

1270

Code List Qualifier Code

X 1

1/3

Code identifying a specific industry code list

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Oral Cavity Area/Tooth Qualifier Code

CODE

DEFINITION

International Standard Designation System for Teeth and Areas of the Oral Cavity

Use when reporting areas of the oral cavity; do not use to report individual teeth.

CODE SOURCE: 135: American Dental Association

Universal National Tooth Designation System

Use when reporting individual teeth; do not use when reporting areas of the oral cavity.

CODE SOURCE: 135: American Dental Association

Required

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Oral Cavity Area/Tooth Code

Situational

C005

Tooth Surface

O 1

To identify one or more tooth surface codes

SITUATIONAL RULE: Required when the tooth surface code was used in the adjudication of the service or was submitted on the service line. If not required by this implementation guide, do not send.

Required

3-1

1369

Tooth Surface Code

M 1

1/2

Code identifying the area of the tooth that was treated

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-2

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when it is necessary to report an additional tooth surface. If not required by this implementation guide, do not send.

Additional tooth surface codes can be carried in TOO03-02 through TOO03-05. The code values are the same as in TOO03-01.

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-3

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when it is necessary to report an additional tooth surface. If not required by this implementation guide, do not send.

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-4

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when it is necessary to report an additional tooth surface. If not required by this implementation guide, do not send.

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Situational

3-5

1369

Tooth Surface Code

O 1

1/2

Code identifying the area of the tooth that was treated

SITUATIONAL RULE: Required when it is necessary to report an additional tooth surface. If not required by this implementation guide, do not send.

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

PLB - PROVIDER ADJUSTMENT

X12 Name:

Provider Level Adjustment

X12 Purpose:

To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service

X12 Syntax:

P0506
If either PLB05 or PLB06 is present, then the other is required.
P0708
If either PLB07 or PLB08 is present, then the other is required.
P0910
If either PLB09 or PLB10 is present, then the other is required.
P1112
If either PLB11 or PLB12 is present, then the other is required.
P1314
If either PLB13 or PLB14 is present, then the other is required.

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when reporting adjustments to the actual payment that cannot be reported using a RAS segment. If not required by this implementation guide, do not send.

TR3 Notes:

These adjustments can either decrease the payment (a positive number) or increase the payment (a negative number). Zero dollar adjustments are not allowed. Some examples of PLB adjustments are a Periodic Interim Payment (loans and loan repayment) or a capitation payment. Multiple adjustments can be placed in one PLB segment, grouped by the provider identified in PLB01 and the period identified in PLB02. Although the PLB reference numbers are not standardized, refer to 1.10.2.9 (Interest and Prompt Payment Discounts), 1.10.2.10 (Capitation and Related Payments or Adjustments), 1.10.2.12 (Balance Forward Processing), 1.10.2.16 (Post Payment Recovery) and 1.10.2.17 (Claim Overpayment Recovery) for code suggestions and usage guidelines.
The codes and notations under PLB03 and its components apply equally to PLB05, 07, 09, 11 and 13.

TR3 Example:

PLB✱1234567890✱20000930✱CV:9876514✱-1.27~

PLB

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