835 Health Care Claim Payment/Advice (005010X221, 005010X221E1, 005010X221A1)

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 N104, if necessary.

TR3 Example:

N1✱PR✱INSURANCE COMPANY OF TIMBUCKTU✱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

O 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Payer Name

Situational

Identification Code Qualifier

O 1

1/2

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

SEGMENT SYNTAX: R0203, 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.Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to:1. Follow a dual use approach in which the HPID or OEID and the Payer Identification Number are both sent.OR2. Follow an early implementation approach in which the HPID or OEID is sent in N104.

CODE

DEFINITION

Centers for Medicare and Medicaid Services PlanID

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

CODE SOURCE 540: Centers for Medicare and Medicaid Services PlanID

Situational

Identification Code

O 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

INDUSTRY NAME: Payer Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

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✱100 MAIN STREET~

✱

✱

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 exists. 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.
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~

✱

✱

✱

✱

✱

✱

✱

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

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

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

O 1

3/15

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

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

O 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.

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

CODE SOURCE 5:Countries, Currencies and Funds

Not Used

309

Location Qualifier

O 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

O 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.

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

CODE SOURCE 5:Countries, Currencies and Funds

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

TR3 Notes:

The ID available in the TRN and 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 qualifying the Reference Identification

CODE

DEFINITION

Payer Identification Number

For Medicare carriers or intermediaries, use this qualifier for the Medicare carrier or intermediary ID number. For Blue Cross and Blue Shield Plans, use this qualifier for the Blue Cross Blue Shield association plan code.

Submitter Identification Number

This is required when the original transaction sender is not the payer or is identified by an identifier other than those already provided. This is not updated by third parties between the payer and the payee. An example of a use for this qualifier is when identifying a clearinghouse that created the 835 when the health plan sent a proprietary format to the clearinghouse.

Health Industry Number (HIN)

CODE SOURCE 121: Health Industry Number

National Association of Insurance Commissioners (NAIC) Code

This is the preferred value when identifying the payer.

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

Required

127

Reference Identification

O 1

1/50

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

Not Used

352

Description

O 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 always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800) 555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number.

TR3 Example:

PER✱CX✱JOHN WAYNE✱TE✱8005551212~

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).

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

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

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

Situational

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

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

INDUSTRY NAME: Payer Contact Communication Number

Situational

365

Communication Number Qualifier

O 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

When used, the value following this code is the extension for the preceding communications contact number.

Facsimile

Telephone

Situational

364

Communication Number

O 1

1/256

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

O 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

O 1

1/256

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:

Required to report technical contact information for this remittance advice.

TR3 Example:

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

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Contact Inq
Reference

O 1

1/20

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

INDUSTRY NAME: Payer Technical 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).

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

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

CODE

DEFINITION

Electronic Mail

Telephone

Recommended

Uniform Resource Locator (URL)

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

Situational

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

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

INDUSTRY NAME: Payer Contact Communication Number

Situational

365

Communication Number Qualifier

O 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

When used, the value following this code is theextension for the preceding communicationscontact number.

Facsimile

Telephone

Uniform Resource Locator (URL)

Situational

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

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 Technical Contact Communication Number

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

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

When used, the value following this code is theextension for the preceding communicationscontact number.

Facsimile

Uniform Resource Locator (URL)

Situational

364

Communication Number

O 1

1/256

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*IC - PAYER WEB SITE

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

TR3 Notes:

This is a direct link to the policy location of the un-secure website.

TR3 Example:

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

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Contact Inq
Reference

O 1

1/20

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

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Uniform Resource Locator (URL)

Required

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

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

Not Used

365

Communication Number Qualifier

O 1

Not Used

364

Communication Number

O 1

1/256

Not Used

365

Communication Number Qualifier

O 1

Not Used

364

Communication Number

O 1

1/256

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.

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 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

O 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Payee Name

Required

Identification Code Qualifier

O 1

1/2

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

SEGMENT SYNTAX: R0203, P0304

CODE

DEFINITION

Federal Taxpayer's Identification Number

Required if provider is not mandated by NPI. For individual providers as payees, use this qualifier to represent the Social Security Number.

Centers for Medicare and Medicaid Services PlanID

Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). This only applies in cases of post payment recovery. See section 1.10.2.16 (Post Payment Recovery) for further information.

CODE SOURCE 540: Centers for Medicare and Medicaid Services PlanID

Centers for Medicare and Medicaid Services National Provider Identifier

This is REQUIRED when the National Provider Identifier is mandated for use and the payee is a covered health care provider under the mandate.

CODE SOURCE 537: Centers for Medicare and Medicaid Services National Provider Identifier

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Payee Identification Code

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

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 the sender needs to communicate the payee address to a transaction receiver, e.g., a VAN or a clearinghouse. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

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 exists. 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.
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~

✱

✱

✱

✱

✱

✱

✱

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

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

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

O 1

3/15

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

INDUSTRY NAME: Payee Postal Zone or ZIP Code

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

Situational

Country Code

O 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.

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

CODE SOURCE 5:Countries, Currencies and Funds

Not Used

309

Location Qualifier

O 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

O 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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

CODE SOURCE 5:Countries, Currencies and Funds

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 qualifying 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 Number

Payee Identification

Federal Taxpayer's Identification Number

This information must be in the N1 segment unless the National Provider ID or the Health Plan Identifier (HPID) or Other Entity Identifier (OEID) was used in N104. For individual providers as payees, use this number to represent the Social Security Number. TJ also represents the Employer Identification Number (EIN). According to the IRS, TIN and EIN can be used interchangeably.

Required

127

Reference Identification

O 1

1/50

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

Not Used

352

Description

O 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 or X; and the remittance is to be sent separately from the payment. The payer is responsible to provide the bank with the instructions on how to deliver the remittance information, if not required by this implementation guide, do not send.

TR3 Notes:

Payer should coordinate this process with their Originating Depository Financial Institution (ODFI).

RDM

✱

✱

✱

✱

✱

Required

756

Report Transmission Code

M 1

1/2

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

CODE

DEFINITION

By Mail

When used, RDM02 must be used.

When BM is used, the remittance information will be mailed to the payee at the address identified in this 1000B loop.

E-Mail

Use with encrypted e-mail.

File Transfer

Use with FTP communications.

On-Line

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

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

Situational

364

Communication Number

O 1

1/256

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, FT, or OL. If not required by this implementation guide, do not send.

Contains URL web address or e-mail 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~
LX✱110210~

✱

Required

554

Assigned Number

M 1

1/6

Number assigned for differentiation within a transaction set

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 for Medicare Part A or when payers and payees outside the Medicare Part A community need to identify provider subsidiaries whose remittance information is contained in the 835 transactions transmitted to a single provider entity [i.e., the corporate office of a hospital chain]. If not required by this implementation guide, do not send.

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 Part A uses data elements TS313, TS315, TS317, TS318 and TS320 through TS324. Each monetary amount element is for that provider for this facility type code for loop 2000.

TR3 Example:

TS3✱123456✱11✱20021031✱10✱130957.66~

TS3

✱

Required

127

Reference Identification

M 1

1/50

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.

Required

1331

Facility Code Value

M 1

1/2

Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.

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

Use this date for the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known, use December 31st of the current year.

Required

380

Quantity

M 1

1/15

Numeric value of quantity

SEMANTIC: TS304 is the total number of claims.

INDUSTRY NAME: Total Claim Count

This is the total number of claims.

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: TS305 is the total of reported charges.

INDUSTRY NAME: Total Claim Charge Amount

This is the total reported charges for all claims.
Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all 782 elements.

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.

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.

Not Used

782

Monetary Amount

O 1

1/18

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: TS317 is the Health Care Financing Administration Common Procedural 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.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: TS318 is the total Health Care Financing Administration Common Procedural 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.

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 CAS segment with a Claim Adjustment Reason Code value of 89.
See TR3 note 3.

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 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.

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

INDUSTRY NAME: Total Patient Reimbursement Amount

See TR3 note 3.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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 noncovered 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.

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.

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.

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.

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.

CLP - CLAIM PAYMENT INFORMATION

X12 Name:

Claim Level Data

X12 Purpose:

To supply information common to all services of a claim

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

For CLP segment occurrence limitations, see section 1.3.2, Other Usage Limitations.

TR3 Example:

CLP✱7722337✱1✱211366.97✱138018.4✱✱12✱119932404007801~

CLP

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

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: Patient Control Number

Use this number for the patient control number assigned by the provider. If the patient control number is not present on the incoming claim, enter a single zero. The value in CLP01 must be identical to any value received as a Claim Submitter's Identifier on the original claim (CLM01 of the ANSI ASC X12 837, if applicable). This data element is the primary key for posting the remittance information into the provider's database. In the case of pharmacy claims, this is the prescription reference number (field 402-02 in the NCPDP 5.1 format).

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 CAS segment in conjunction with this claim status code.

CODE

DEFINITION

Processed as Primary

Use this code if the claim was adjudicated by the current payer as primary regardless of whether any part of the claim was paid.

Processed as Secondary

Use this code if the claim was adjudicated by the current payer as secondary regardless of whether any part of the claim was paid.

Processed as Tertiary

Use this code if the claim was adjudicated by the current payer as tertiary (or subsequent) regardless of whether any part of the claim was paid.

Denied

Usage of this code would apply if the Patient/Subscriber is not recognized, and the claim was not forwarded to another payer.

Processed as Primary, Forwarded to Additional Payer(s)

When this code is used, the Crossover Carrier Name NM1 segment is required.

Processed as Secondary, Forwarded to Additional Payer(s)

When this code is used, the Crossover Carrier Name NM1 segment is required.

Processed as Tertiary, Forwarded to Additional Payer(s)

When this code is used, the Crossover Carrier Name NM1 segment is required.

Reversal of Previous Payment

See section 1.10.2.8 for usage information.

Not Our Claim, Forwarded to Additional Payer(s)

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

Predetermination Pricing Only - No Payment

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

See 1.10.2.1, Balancing, in this implementation guide for additional information.
Use this monetary amount for the submitted charges for this claim. The amount can be positive, zero or negative. An example of a situation with a negative charge is a reversal claim. See section 1.10.2.8 for additional information.
Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements.

Required

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, Balancing, in this implementation guide for additional information. See section 1.10.2.9 for information about interest considerations.
Use this monetary amount for the amount paid for this claim. It can be positive, zero or negative, but the value in BPR02 may not be negative.

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CLP05 is the patient responsibility amount.

SITUATIONAL RULE: Required when the patient's responsibility is greater than 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 CAS segments at the 2100 (CLP) or 2110 (SVC) loop level with a Claim Adjustment Group (CAS01) code of PR (Patient Responsibility).
Use this monetary amount for the payer's statement of the patient responsibility amount for this claim, which can include such items as deductible, non-covered services, co-pay and co-insurance. This is not used for reversals. See section 1.10.2.8, Reversals and Corrections, for additional information.

Required

1032

Claim Filing Indicator Code

O 1

1/2

Code identifying type of claim

For many providers to electronically post the 835 remittance data to their patient accounting systems without human intervention, a unique, provider-specific insurance plan code is needed. This code allows the provider to separately identify and manage the different product lines or contractual arrangements between the payer and the provider. Because most payers maintain the same Originating Company Identifier in the TRN03 or BPR10 for all product lines or contractual relationships, the CLP06 is used by the provider as a table pointer in combination with the TRN03 or BPR10 to identify the unique, provider-specific insurance plan code needed to post the payment without human intervention. The value should mirror the value received in the original claim (2-005 SBR09 of the 837), if applicable, or provide the value as assigned or edited by the payer. For example the BL from the SBR09 in the 837 would be returned as 12, 13, 15, in the 835 when more details are known. The 837 SBR09 code CI (Commercial Insurance) is generic, if through adjudication the specific type of plan is obtained a more specific code must be returned in the 835.
The 837 and 835 transaction code lists for this element are not identical by design. There are some business differences between the two transactions. When a code from the 837 is not available in the 835 another valid code from the 835 must be assigned by the payer.

CODE

DEFINITION

Preferred Provider Organization (PPO)

This code is also used for Blue Cross/Blue Shield participating provider arrangements.

Point of Service (POS)

Exclusive Provider Organization (EPO)

Indemnity Insurance

This code is also used for Blue Cross/Blue Shield non-participating provider arrangements.

Health Maintenance Organization (HMO) Medicare Risk

Dental Maintenance Organization

Automobile Medical

Champus

Disability

Health Maintenance Organization

Liability Medical

Medicare Part A

Medicare Part B

Medicaid

Other Federal Program

Use this code for the Black Lung Program.

Title V

Veterans Affairs Plan

Workers' Compensation Health Claim

Mutually Defined

Required

127

Reference Identification

O 1

1/50

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.

Situational

1331

Facility Code Value

O 1

1/2

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

Since professional or dental claims can have different place of service codes for services within a single claim, default to the place of service of the first service line when the service lines are not all for the same place of service.
This number was received in CLM05-1 of the 837 claim.

Situational

1325

Claim Frequency Type Code

O 1

Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type

INDUSTRY NAME: Claim Frequency Code

This number was received in CLM05-3 of the 837 Claim.

CODE SOURCE 235:Claim Frequency Type Code

Not Used

1352

Patient Status Code

O 1

1/2

Situational

1354

Diagnosis Related Group (DRG) Code

O 1

1/4

Code indicating a patient's diagnosis group based on a patient's illness, diseases, and medical problems

SITUATIONAL RULE: Required for institutional claims when the claim was adjudicated using a DRG. If not required by this implementation guide, do not send.

CODE SOURCE 229:Diagnosis Related Group Number (DRG)

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

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

SITUATIONAL RULE: Required for institutional claims when the claim was adjudicated using a DRG. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Related Group (DRG) Weight

This is the adjudicated DRG Weight.

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.

Not Used

1073

Yes/No Condition or Response Code

O 1

CAS - CLAIM ADJUSTMENT

X12 Name:

Claims Adjustment

X12 Purpose:

To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

X12 Syntax:

L050607
If CAS05 is present, then at least one of CAS06 or CAS07 are required.
C0605
If CAS06 is present, then CAS05 is required.
C0705
If CAS07 is present, then CAS05 is required.
L080910
If CAS08 is present, then at least one of CAS09 or CAS10 are required.
C0908
If CAS09 is present, then CAS08 is required.
C1008
If CAS10 is present, then CAS08 is required.
L111213
If CAS11 is present, then at least one of CAS12 or CAS13 are required.
C1211
If CAS12 is present, then CAS11 is required.
C1311
If CAS13 is present, then CAS11 is required.
L141516
If CAS14 is present, then at least one of CAS15 or CAS16 are required.
C1514
If CAS15 is present, then CAS14 is required.
C1614
If CAS16 is present, then CAS14 is required.
L171819
If CAS17 is present, then at least one of CAS18 or CAS19 are required.
C1817
If CAS18 is present, then CAS17 is required.
C1917
If CAS19 is present, then CAS17 is required.

X12 Set Notes:

NOTE: The CAS segment is used to reflect changes to amounts within Table 2.

X12 Comments:

Adjustment information is intended to help the provider balance the remittance information. Adjustment amounts should 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 and/or quantities are being adjusted at the claim level. If not required by this implementation guide, do not send.

TR3 Notes:

Payers must use this CAS segment to report claim level adjustments that cause the amount paid to differ from the amount originally charged. See 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information.
See the SVC TR3 Note #1 for details about per diem adjustments.
A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment must be the first non-zero adjustment and is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).

TR3 Example:

CAS✱PR✱1✱793✱✱3✱25~CAS✱CO✱131✱250~

CAS

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

1033

Claim Adjustment Group Code

M 1

1/2

Code identifying the general category of payment adjustment

Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.)

CODE

DEFINITION

Contractual Obligations

Use this code when a joint payer/payee contractual agreement or a regulatory requirement resulted in an adjustment.

Other adjustments

Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13.

Payor Initiated Reductions

Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments).

Patient Responsibility

Required

1034

Claim Adjustment Reason Code

M 1

1/5

Code identifying the detailed reason the adjustment was made

INDUSTRY NAME: Adjustment Reason Code

Required to report a non-zero adjustment applied at the claim level for the claim adjustment group code reported in CAS01.

CODE SOURCE 139:Claim Adjustment Reason Code

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: CAS03 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.
Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS04 is the units of service being adjusted.

SITUATIONAL RULE: Required when the CAS02 adjustment reason code is related to non-covered days. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

See section 1.10.2.4.1 for additional information.
A positive value decreases the covered days, and a negative number increases the covered days.

Situational

1034

Claim Adjustment Reason Code

O 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L050607, C0605, C0705

SITUATIONAL RULE: Required when an additional non-zero adjustment, beyond what has already been supplied, applies to the claim adjustment group code used in CAS01. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139:Claim Adjustment Reason Code

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CAS06 is the amount of the adjustment.

SEGMENT SYNTAX: L050607, C0605

SITUATIONAL RULE: Required when CAS05 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

See CAS03.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS07 is the units of service being adjusted.

SEGMENT SYNTAX: L050607, C0705

SITUATIONAL RULE: Required when CAS05 is present and is related to non-covered days. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

See CAS04.

Situational

1034

Claim Adjustment Reason Code

O 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L080910, C0908, C1008

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139:Claim Adjustment Reason Code

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CAS09 is the amount of the adjustment.

SEGMENT SYNTAX: L080910, C0908

SITUATIONAL RULE: Required when CAS08 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

See CAS03.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS10 is the units of service being adjusted.

SEGMENT SYNTAX: L080910, C1008

SITUATIONAL RULE: Required when CAS08 is present and is related to non-covered days. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

See CAS04.

Situational

1034

Claim Adjustment Reason Code

O 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L111213, C1211, C1311

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139:Claim Adjustment Reason Code

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CAS12 is the amount of the adjustment.

SEGMENT SYNTAX: L111213, C1211

SITUATIONAL RULE: Required when CAS11 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

See CAS03.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS13 is the units of service being adjusted.

SEGMENT SYNTAX: L111213, C1311

SITUATIONAL RULE: Required when CAS11 is present and is related to non-covered days. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

See CAS04.

Situational

1034

Claim Adjustment Reason Code

O 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L141516, C1514, C1614

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139:Claim Adjustment Reason Code

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CAS15 is the amount of the adjustment.

SEGMENT SYNTAX: L141516, C1514

SITUATIONAL RULE: Required when CAS14 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

See CAS03.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS16 is the units of service being adjusted.

SEGMENT SYNTAX: L141516, C1614

SITUATIONAL RULE: Required when CAS14 is present and is related to non-covered days. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

See CAS04.

Situational

1034

Claim Adjustment Reason Code

O 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L171819, C1817, C1917

INDUSTRY NAME: Adjustment Reason Code

CODE SOURCE 139:Claim Adjustment Reason Code

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CAS18 is the amount of the adjustment.

SEGMENT SYNTAX: L171819, C1817

SITUATIONAL RULE: Required when CAS17 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

See CAS03.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS19 is the units of service being adjusted.

SEGMENT SYNTAX: L171819, C1917

SITUATIONAL RULE: Required when CAS17 is present and is related to non-covered days. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

See CAS04.

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:

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

TR3 Example:

NM1✱QC✱1✱SHEPHARD✱SAM✱O✱✱✱HN✱666666666A~

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 qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Situational

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required for all claims that are not Retail Pharmacy claims or for Retail Pharmacy claims when the information is known. 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 it is known. 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 has a middle name or initial and it is known. 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 this information is necessary for identification of the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Name Suffix

An example of this is when a Junior and Senior are covered under the same subscriber.

Situational

Identification Code Qualifier

O 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when the patient identifier (NM109) is known or was reported on the healthcare claim. If not required by this implementation guide, do not send.

CODE

DEFINITION

Social Security Number

Health Insurance Claim (HIC) Number

Standard Unique Health Identifier for each Individual in the United States

Use this code if mandated in a final Federal Rule.

Member Identification Number

Medicaid Recipient Identification Number

Situational

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when the patient identifier is known or was reported on the health care claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

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

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 reported on the claim (for example 837 2010BA loop Subscriber Name NM1 Segment when the patient was reported in the 2010CA loop Patient Name NM1 Segment).

TR3 Example:

NM1✱IL✱1✱SHEPARD✱JESSICA✱✱✱✱MI✱999887777A~

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 qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when the last name (NM102=1) or organization name (NM102=2) is known. 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 is known. 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 is known. 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), 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: Subscriber Name Suffix

For example, use when necessary to differentiate between a Junior and Senior under the same contract.

Required

Identification Code Qualifier

O 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Federal Taxpayer's Identification Number

Not Used when NM102=1.

Standard Unique Health Identifier for each Individual in the United States

Use this code if mandated in a final Federal Rule.

Member Identification Number

The code MI is intended to identify that the subscriber's identification number as assigned by the payer will be conveyed in NM109. Payers use different terminology to convey the same number, therefore, the 835 workgroup recommends using MI (Member Identification number) to convey the same categories of numbers as represented in the 837 IGs for the inbound claims.

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Subscriber Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

NM1*74 - CORRECTED PATIENT/INSURED 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 needed to provide corrected information about the patient or insured. If not required by this implementation guide, do not send.

TR3 Notes:

Since the patient is always the insured for Medicare and Medicaid, this segment always provides corrected patient information for Medicare and Medicaid. For other carriers, this will always be the corrected insured information.

TR3 Example:

NM1✱74✱1✱SHEPARD✱SAMUEL✱O✱✱✱C✱666666666A~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Corrected Insured

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when the insured is a person (NM102=1) AND the submitted vs adjudicated data is different. If not required by this implementation guide, do not send.

INDUSTRY NAME: Corrected Patient or Insured Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the insured is a person (NM102=1) AND the submitted vs adjudicated data is different. If not required by this implementation guide, do not send.

INDUSTRY NAME: Corrected Patient or Insured First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when the insured is a person (NM102=1) AND the submitted vs adjudicated data is different AND the information is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Corrected Patient or Insured Middle Name

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 insured is a person (NM102=1) and corrected information for the insured is available and this information is necessary for identification of the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Corrected Patient or Insured Name Suffix

Situational

Identification Code Qualifier

O 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when a value is reported in NM109. If not required by this implementation guide, do not send.

CODE

DEFINITION

Insured's Changed Unique Identification Number

Situational

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

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

INDUSTRY NAME: Corrected Insured Identification Indicator

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

NM1*82 - 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 rendering provider is different from the payee. If not required by this implementation guide, do not send.

TR3 Notes:

This segment provides information about the rendering provider. An identification number is provided in NM109.
This information is provided to facilitate identification of the claim within a payee's system. Other providers (e.g., Referring provider, supervising provider) related to the claim but not directly related to the payment are not supported and are not necessary for claim identification.

TR3 Example:

NM1✱82✱2✱✱✱✱✱✱XX✱12345678~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Rendering Provider

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when a unique name is necessary for identification of the provider identified in NM109. If not required, may be provided at sender's discretion, but cannot be required by the receiver.

INDUSTRY NAME: Rendering Provider Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Rendering Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

INDUSTRY NAME: Rendering Provider Middle Name or Initial

If this data element is used and contains only one character, it represents 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 Servicing Provider is a person (NM102=1), NM103 is used and this information is necessary for identification of the individual, for instance when a Junior and Senior are both providers in the same practice. If not required by this implementation guide, do not send.

INDUSTRY NAME: Rendering Provider Name Suffix

Required

Identification Code Qualifier

O 1

1/2

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

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Blue Cross Provider Number

Blue Shield Provider Number

Federal Taxpayer's Identification Number

This is the preferred ID until the National Provider ID is mandated and applicable.
For individual providers as payees, use this qualifier to represent the Social Security Number.

Medicaid Provider Number

Provider Commercial Number

State License Number

Unique Physician Identification Number (UPIN)

Centers for Medicare and Medicaid Services National Provider Identifier

Required value if the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate. Otherwise, one of the other listed codes may be used.

CODE SOURCE 537: Centers for Medicare and Medicaid Services National Provider Identifier

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Rendering Provider Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

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.

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 qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Coordination of Benefits 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

O 1

1/2

Code designating 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

Centers for Medicare and Medicaid Services PlanID

Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used.

CODE SOURCE 540: Centers for Medicare and Medicaid Services PlanID

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Coordination of Benefits Carrier Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

NM1*PR - CORRECTED PRIORITY PAYER 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 current payer believes that another payer has priority for making a payment and the claim is not being automatically transferred to that payer. If not required by this implementation guide, do not send.

TR3 Notes:

Provide any reference numbers in NM109. Use of this segment identifies the priority payer. Do not use this segment when the Crossover Carrier NM1 segment is used.

TR3 Example:

NM1✱PR✱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

Payer

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Corrected Priority Payer Name

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

O 1

1/2

Code designating 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

Centers for Medicare and Medicaid Services PlanID

Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used.

CODE SOURCE 540: Centers for Medicare and Medicaid Services PlanID

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

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

1035

Name Last or Organization Name

O 1

1/60

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 Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when a corrected priority payer has been identified in another NM1 segment AND the name or ID of the other subscriber is known. If not required by this implementation guide, do not send.

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✱Smith✱Jane~

NM1

✱

✱

Entity Type
Qualifier

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

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 qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

O 1

1/60

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) 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

When only one character is present this is assumed to be 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

O 1

1/2

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

SEGMENT SYNTAX: P0809

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

CODE

DEFINITION

Federal Taxpayer's Identification Number

Not Used when NM102=1.

Standard Unique Health Identifier for each Individual in the United States

Use this code if mandated in a final Federal Rule.

Member Identification Number

Use this code when supplying the number used for identification of the subscriber in NM109.

Situational

Identification Code

O 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

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

MIA - INPATIENT ADJUDICATION INFORMATION

X12 Name:

Medicare Inpatient Adjudication

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required for all inpatient claims when there is a need to report Remittance Advice Remark Codes at the claim level or, the claim is paid by Medicare or Medicaid under the Prospective Payment System (PPS). If not required by this implementation guide, do not send.

TR3 Notes:

When used outside of the Medicare and Medicaid community only MIA01, 05, 20, 21, 22 and 23 may be used.
Either MIA or MOA may appear, but not both.
This segment must not be used for covered days or lifetime reserve days. For covered or lifetime reserve days, use the Supplemental Claim Information Quantities Segment in the Claim Payment Loop.
All situational quantities and/or monetary amounts in this segment are required when the value of the item is different than zero.

TR3 Example:

MIA✱0✱✱✱138018.4~

MIA

✱

Required

380

Quantity

M 1

1/15

Numeric value of quantity

SEMANTIC: MIA01 is the covered days.

INDUSTRY NAME: Covered Days or Visits Count

Implementers utilizing the MIA segment always transmit the number zero. See the QTY segment at the claim level for covered days or visits count.

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 when the payer is Medicare or Medicaid and the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: PPS Operating Outlier Amount

See TR3 note 4.
Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements.

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 payer is Medicare or Medicaid and 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 payer is Medicare or Medicaid and the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim DRG Amount

Situational

127

Reference Identification

O 1

1/50

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

SEMANTIC: MIA05 is the Claim Payment Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when a claim level Claim Payment Remark Code applies to this claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MIA06 is the disproportionate share amount.

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

INDUSTRY NAME: Claim Disproportionate Share Amount

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 Medicare or Medicaid is the payer and the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim MSP Pass-through Amount

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 Medicare or Medicaid is the payer and the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim PPS Capital Amount

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 Medicare or Medicaid is the payer and the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: PPS-Capital FSP DRG Amount

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 Medicare or Medicaid is the payer and the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: PPS-Capital HSP DRG Amount

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 Medicare or Medicaid is the payer and the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: PPS-Capital DSH DRG Amount

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MIA12 is the old capital amount.

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

INDUSTRY NAME: Old Capital Amount

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 Medicare or Medicaid is the payer and the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: PPS-Capital IME amount

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

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

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

INDUSTRY NAME: PPS-Operating Hospital Specific DRG Amount

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: MIA15 is the cost report days.

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

INDUSTRY NAME: PPS-Operating Federal Specific DRG Amount

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 Medicare or Medicaid is the payer and the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim PPS Capital Outlier Amount

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MIA18 is the indirect teaching amount.

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

INDUSTRY NAME: Claim Indirect Teaching Amount

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 Medicare or Medicaid is the payer and the value is different than zero. If not required by this implementation guide, do not send.

INDUSTRY NAME: Nonpayable Professional Component Amount

Situational

127

Reference Identification

O 1

1/50

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

SEMANTIC: MIA20 is the Claim Payment Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when an additional Claim Payment Remark Code applies to this entire claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

Situational

127

Reference Identification

O 1

1/50

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

SEMANTIC: MIA21 is the Claim Payment Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when an additional Claim Payment Remark Code applies to this entire claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

Situational

127

Reference Identification

O 1

1/50

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

SEMANTIC: MIA22 is the Claim Payment Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when an additional Claim Payment Remark Code applies to this entire claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

Situational

127

Reference Identification

O 1

1/50

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

SEMANTIC: MIA23 is the Claim Payment Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when an additional Claim Payment Remark Code applies to this entire claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: MIA24 is the capital exception amount.

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

INDUSTRY NAME: PPS-Capital Exception Amount

MOA - OUTPATIENT ADJUDICATION INFORMATION

X12 Name:

Medicare Outpatient Adjudication

X12 Purpose:

To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required for outpatient/professional claims where there is a need to report a Remittance Advice Remark Code at the claim level or when the payer is Medicare or Medicaid and MOA01, 02, 08 or 09 are non-zero. If not required by this implementation guide, do not send.

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✱✱✱MA01~

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 for a Medicare or Medicaid claim. 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 Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount.

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

INDUSTRY NAME: Claim HCPCS Payable Amount

Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements.

Situational

127

Reference Identification

O 1

1/50

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

SEMANTIC: MOA03 is the Claim Payment Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when a Claim Payment Remark Code applies to this entire claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

Situational

127

Reference Identification

O 1

1/50

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

SEMANTIC: MOA04 is the Claim Payment Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when an additional Claim Payment Remark Code applies to this entire claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

Situational

127

Reference Identification

O 1

1/50

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

SEMANTIC: MOA05 is the Claim Payment Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when an additional Claim Payment Remark Code applies to this entire claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

Situational

127

Reference Identification

O 1

1/50

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

SEMANTIC: MOA06 is the Claim Payment Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when an additional Claim Payment Remark Code applies to this entire claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

Situational

127

Reference Identification

O 1

1/50

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

SEMANTIC: MOA07 is the Claim Payment Remark Code. See Code Source 411.

SITUATIONAL RULE: Required when an additional Claim Payment Remark Code applies to this entire claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Payment Remark Code

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 for a Medicare or Medicaid claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim ESRD Payment Amount

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 for a Medicare or Medicaid claim. If not required by this implementation guide, do not send.

INDUSTRY NAME: Nonpayable Professional Component Amount

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 additional reference numbers specific to the claim in the CLP segment are provided to identify information used in the process of adjudicating this claim. If not required by this implementation guide, do not send.

TR3 Example:

REF✱EA✱666123~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Group or Policy Number

Use this code when conveying the Group Number in REF02.

Member Identification Number

Employee Identification Number

Group Number

This is the Other Insured Group Number. This is required when a Corrected Priority Payer is identified in the NM1 segment and the Group Number of the other insured for that payer is known.

Repriced Claim Reference Number

Adjusted Repriced Claim Reference Number

Authorization Number

Use this qualifier only when supplying an authorization number that was assigned by the adjudication process and was not provided prior to the services. Do not use this qualifier when reporting the same number as reported in the claim as the prior authorization or pre-authorization number.

Class of Contract Code

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

Medical Record Identification Number

Original Reference Number

When this is a correction claim and CLP07 does not equal the CLP07 value from the original claim payment, one iteration of this REF segment using this qualifier is REQUIRED to identify the original claim CLP07 value in REF02. See section 1.10.2.8, Reversals and Corrections, for additional information.

Prior Authorization Number

Use this qualifier when reporting the number received with the original claim as a pre-authorization number (in the 837 that was at table 2, position 180, REF segment, using the same qualifier of G1).

Predetermination of Benefits Identification Number

Insurance Policy Number

Use this code when conveying the Policy Number in REF02.

Social Security Number

Required

127

Reference Identification

O 1

1/50

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

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF - RENDERING PROVIDER 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 rendering provider identification numbers not already reported in the Provider NM1 segment for this claim were submitted on the original claim and impacted adjudication. If not required by this implementation guide, do not send.

TR3 Notes:

The NM1 segment always contains the primary reference number.

TR3 Example:

REF✱1C✱12345678~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Blue Cross Provider Number

Blue Shield Provider Number

Medicare Provider Number

Medicaid Provider Number

Provider UPIN Number

CHAMPUS Identification Number

Facility ID Number

National Council for Prescription Drug Programs Pharmacy Number

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

Provider Commercial Number

Location Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Rendering Provider Secondary Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

DTM - STATEMENT FROM OR TO 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 "Statement From or To Dates" are not supplied at the service (2110 loop) level. If not required by this implementation guide, may be provided at senders discretion, but cannot be required by the receiver.

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.
For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment.
When payment is being made in advance of services, the use of future dates is allowed.

TR3 Example:

DTM✱233✱20020916~

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

If the claim statement period start date is conveyed without a subsequent claim statement period end date, the end date is assumed to be the same as the start date. This date or code 233 is required when service level dates are not provided in the remittance advice.

233

Claim Statement Period End

If a claim statement period end date is conveyed without a claim statement period start date, then the start date is assumed to be different from the end date but not conveyed at the payer's discretion. See the note on code 232.

Required

373

Date

O 1

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

SEGMENT SYNTAX: R020305

INDUSTRY NAME: Claim Date

Not Used

337

Time

O 1

4/8

Not Used

623

Time Code

O 1

Not Used

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

1251

Date Time Period

O 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✱20011001~

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

O 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

O 1

4/8

Not Used

623

Time Code

O 1

Not Used

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

1251

Date Time Period

O 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 whenever state or federal regulations or the provider contract mandate interest payment or prompt payment discounts based upon the receipt date of the claim by the payer. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

TR3 Example:

DTM✱050✱20011124~

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

O 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

O 1

4/8

Not Used

623

Time Code

O 1

Not Used

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

1251

Date Time Period

O 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:

When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800)555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number.

TR3 Example:

PER✱CX✱✱TE✱8005551212~

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 the prior contact segment (PER). If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Contact Name

Required

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Electronic Mail

Facsimile

Telephone

Required

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Claim Contact Communications Number

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when required per ASC X12 syntax when PER06 is sent. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Telephone Extension

When used, the value following this code is the extension for the preceding communications contact number.

Facsimile

Telephone

Situational

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when a second claim specific communications contact number exists. If not required by this implementation guide, do not send.

INDUSTRY NAME: Claim Contact Communications Number

Situational

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when required per ASC X12 syntax when PER08 is sent. If not required by this implementation guide, do not send.

CODE

DEFINITION

Telephone Extension

Situational

364

Communication Number

O 1

1/256

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

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.

TR3 Example:

AMT✱T✱49~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

Coverage Amount

Use this monetary amount to report the total covered charges.

This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan. This excludes charges considered not covered (i.e. per day television or telephone charges) but includes reductions to payments of covered services (i.e. reductions for amounts over fee schedule and patient deductibles).

Discount Amount

Prompt Pay Discount Amount

See section 1.10.2.9 for additional information.

Per Day Limit

Patient Amount Paid

Use this monetary amount for the amount the patient has already paid.

Interest

See section 1.10.2.9 for additional information.

Negative Ledger Balance

Used only by Medicare Part A and Medicare Part B.

Tax

Total Claim Before Taxes

Used only when tax also applies to the claim.

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

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

✱

✱

✱

✱

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

Visits

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

O 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

O 1

1/30

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, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send.

TR3 Notes:

See section 1.10.2.1.1 (Service Line Balancing) for additional information.
The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CAS*CO*78*25~). See section 1.10.2.4.1 for additional information.
See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information.

TR3 Example:

SVC✱HC:99214✱100✱80~

SVC

✱

✱

✱

✱

✱

✱

✱

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 Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132).

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.

This is the adjudicated medical procedure information.
This code is a composite data structure.

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 SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7.

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

Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC.

CODE SOURCE 130: Healthcare Common Procedural Coding System

Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code

Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System.

CODE SOURCE 716: Health Insurance Prospective Payment System (HIPPS) Rate Code for Skilled Nursing Facilities

Home Infusion EDI Coalition (HIEC) Product/Service Code

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property & Casualty claims/encounters that are not covered under HIPAA.

CODE SOURCE 513: Home Infusion EDI Coalition (HIEC) Product/Service Code List

National Drug Code in 5-4-2 Format

CODE SOURCE 240: National Drug Code by Format

National Health Related Item Code in 4-6 Format

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names National Health Related Item Code in 4-6 Format Codes as an allowable code set under HIPAA. 2) For Property & Casualty claims/encounters that are not covered under HIPAA.

CODE SOURCE 240: National Drug Code by Format

National Uniform Billing Committee (NUBC) UB92 Codes

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

U.P.C. Consumer Package Code (1-5-5)

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names U.P.C. Consumer Package Code (1-5-5) Codes as an allowable code set under HIPAA. 2) For Property & Casualty claims/encounters that are not covered under HIPAA.

Advanced Billing Concepts (ABC) Codes

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used in transactions covered under HIPAA by parties registered in the pilot project and their trading partners.

CODE SOURCE 843: Advanced Billing Concepts (ABC) Codes

Required

1-2

234

Product/Service ID

M 1

1/48

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 SVC01-1.

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

1/48

Required

782

Monetary Amount

M 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.
Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements.

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 CAS segments of this loop. See 1.10.2.1, Balancing, for additional information.

Situational

234

Product/Service ID

O 1

1/48

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

If the original claim and adjudication only referenced an NUBC revenue code, that is supplied in SVC01 and this element is not used.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SVC05 is the paid units of service.

SITUATIONAL RULE: Required when the paid units of service are different than one. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

INDUSTRY NAME: Units of Service Paid Count

If not present, the value is assumed to be one.

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.

SITUATIONAL RULE: Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send.

This code is a composite data structure.
This is the Submitted Procedure Code information.

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 SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7.

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

Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

Because the CPT codes of the American Medical Association are also level 1 HCPCS codes, they are reported under the code HC.

CODE SOURCE 130: Healthcare Common Procedural Coding System

Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code

Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System.

CODE SOURCE 716: Health Insurance Prospective Payment System (HIPPS) Rate Code for Skilled Nursing Facilities

Home Infusion EDI Coalition (HIEC) Product/Service Code

CODE SOURCE 513: Home Infusion EDI Coalition (HIEC) Product/Service Code List

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

Advanced Billing Concepts (ABC) Codes

This qualifier can only be used in transactions covere under HIPAA by parties registered in the pilot project and their trading partners.

CODE SOURCE 843: Advanced Billing Concepts (ABC) Codes

Required

6-2

234

Product/Service ID

M 1

1/48

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

1/48

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

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 claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.

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 predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment.
When payment is being made in advance of services, the use of future dates is allowed.

TR3 Example:

DTM✱472✱20021031~

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

This qualifier is required for reporting the beginning of multi-day services. If not required by this implementation guide, do not send.

151

Service Period End

This qualifier is required for reporting the end of multi-day services. If not required by this implementation guide, do not send.

472

Service

This qualifier is required to indicate a single day service. If not required by this implementation guide, do not send.

Required

373

Date

O 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

O 1

4/8

Not Used

623

Time Code

O 1

Not Used

1250

Date Time Period Format Qualifier

O 1

2/3

Not Used

1251

Date Time Period

O 1

1/35

CAS - SERVICE ADJUSTMENT

X12 Name:

Claims Adjustment

X12 Purpose:

To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

X12 Syntax:

L050607
If CAS05 is present, then at least one of CAS06 or CAS07 are required.
C0605
If CAS06 is present, then CAS05 is required.
C0705
If CAS07 is present, then CAS05 is required.
L080910
If CAS08 is present, then at least one of CAS09 or CAS10 are required.
C0908
If CAS09 is present, then CAS08 is required.
C1008
If CAS10 is present, then CAS08 is required.
L111213
If CAS11 is present, then at least one of CAS12 or CAS13 are required.
C1211
If CAS12 is present, then CAS11 is required.
C1311
If CAS13 is present, then CAS11 is required.
L141516
If CAS14 is present, then at least one of CAS15 or CAS16 are required.
C1514
If CAS15 is present, then CAS14 is required.
C1614
If CAS16 is present, then CAS14 is required.
L171819
If CAS17 is present, then at least one of CAS18 or CAS19 are required.
C1817
If CAS18 is present, then CAS17 is required.
C1917
If CAS19 is present, then CAS17 is required.

X12 Set Notes:

NOTE: The CAS segment is used to reflect changes to amounts within Table 2.

X12 Comments:

Adjustment information is intended to help the provider balance the remittance information. Adjustment amounts should 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:

An example of this level of CAS is the reduction for the part of the service charge that exceeds the usual and customary charge for the service. See sections 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information.
A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).

TR3 Example:

CAS✱PR✱1✱793✱✱3✱25~CAS✱CO✱131✱250~

CAS

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

1033

Claim Adjustment Group Code

M 1

1/2

Code identifying the general category of payment adjustment

CODE

DEFINITION

Contractual Obligations

Use this code when a joint payer/payee agreement or a regulatory requirement has resulted in an adjustment.

Other adjustments

Avoid using the Other Adjustment Group Code (OA) except for business situations described in sections 1.10.2.6, 1.10.2.7 and 1.10.2.13.

Payor Initiated Reductions

Patient Responsibility

Required

1034

Claim Adjustment Reason Code

M 1

1/5

Code identifying the detailed reason the adjustment was made

INDUSTRY NAME: Adjustment Reason Code

Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01.

CODE SOURCE 139:Claim Adjustment Reason Code

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: CAS03 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 and CLP04.
Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). This applies to all subsequent 782 elements.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS04 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 number decreases paid units, and a negative value increases paid units.

Situational

1034

Claim Adjustment Reason Code

O 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L050607, C0605, C0705

SITUATIONAL RULE: Required when an additional non-zero adjustment, beyond what has already been supplied, applies to the service for the claim adjustment group code used in CAS01. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Reason Code

See CAS02.

CODE SOURCE 139:Claim Adjustment Reason Code

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CAS06 is the amount of the adjustment.

SEGMENT SYNTAX: L050607, C0605

SITUATIONAL RULE: Required when CAS05 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

See CAS03.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS07 is the units of service being adjusted.

SEGMENT SYNTAX: L050607, C0705

SITUATIONAL RULE: Required when CAS05 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

See CAS04.

Situational

1034

Claim Adjustment Reason Code

O 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L080910, C0908, C1008

INDUSTRY NAME: Adjustment Reason Code

See CAS02.

CODE SOURCE 139:Claim Adjustment Reason Code

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CAS09 is the amount of the adjustment.

SEGMENT SYNTAX: L080910, C0908

SITUATIONAL RULE: Required when CAS08 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

See CAS03.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS10 is the units of service being adjusted.

SEGMENT SYNTAX: L080910, C1008

SITUATIONAL RULE: Required when CAS08 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

See CAS04.

Situational

1034

Claim Adjustment Reason Code

O 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L111213, C1211, C1311

INDUSTRY NAME: Adjustment Reason Code

See CAS02.

CODE SOURCE 139:Claim Adjustment Reason Code

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CAS12 is the amount of the adjustment.

SEGMENT SYNTAX: L111213, C1211

SITUATIONAL RULE: Required when CAS11 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

See CAS03.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS13 is the units of service being adjusted.

SEGMENT SYNTAX: L111213, C1311

SITUATIONAL RULE: Required when CAS11 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

See CAS04.

Situational

1034

Claim Adjustment Reason Code

O 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L141516, C1514, C1614

INDUSTRY NAME: Adjustment Reason Code

See CAS02.

CODE SOURCE 139:Claim Adjustment Reason Code

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CAS15 is the amount of the adjustment.

SEGMENT SYNTAX: L141516, C1514

SITUATIONAL RULE: Required when CAS14 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

See CAS03.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS16 is the units of service being adjusted.

SEGMENT SYNTAX: L141516, C1614

SITUATIONAL RULE: Required when CAS14 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

See CAS04.

Situational

1034

Claim Adjustment Reason Code

O 1

1/5

Code identifying the detailed reason the adjustment was made

SEGMENT SYNTAX: L171819, C1817, C1917

INDUSTRY NAME: Adjustment Reason Code

See CAS02.

CODE SOURCE 139:Claim Adjustment Reason Code

Situational

782

Monetary Amount

O 1

1/18

Monetary amount

SEMANTIC: CAS18 is the amount of the adjustment.

SEGMENT SYNTAX: L171819, C1817

SITUATIONAL RULE: Required when CAS17 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Amount

See CAS03.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: CAS19 is the units of service being adjusted.

SEGMENT SYNTAX: L171819, C1917

SITUATIONAL RULE: Required when CAS17 is present and is related to a units of service adjustment. If not required by this implementation guide, do not send.

INDUSTRY NAME: Adjustment Quantity

See CAS04.

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 related service specific reference identifiers were used in the process of adjudicating this service. If not required by this implementation guide, do not send.

TR3 Example:

REF✱RB✱100~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Ambulatory Patient Group (APG) Number

APC

Ambulatory Payment Classification

CODE SOURCE 468: Ambulatory Payment Classification

Authorization Number

Attachment Code

Prior Authorization Number

Predetermination of Benefits Identification Number

Location Number

This is the Payer's identification for the provider location. This is REQUIRED when the specific site of service affected the payment of the claim.

Rate code number

Rate Code Number reflects Ambulatory Surgical Center (ASC) rate for Medicare, either 0, 50, 100 or 150%.

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Provider Identifier

Not Used

352

Description

O 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 in the 837, which is utilized by the provider for tracking purposes. See section 1.10.2.11 and 1.10.2.14.1 for additional information on usage with split claims or services. Note - the value in REF02 can include alpha characters.

TR3 Example:

REF✱6R✱A78910~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Provider Control Number

Required

127

Reference Identification

O 1

1/50

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

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF - RENDERING 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 rendering provider for this service is different than the rendering provider applicable at the claim level. If not required by this implementation guide, do not send.

TR3 Example:

REF✱HPI✱1234567891~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

State License Number

Blue Cross Provider Number

Blue Shield Provider Number

Medicare Provider Number

Medicaid Provider Number

Provider UPIN Number

CHAMPUS Identification Number

Facility ID Number

National Council for Prescription Drug Programs Pharmacy Number

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

Provider Commercial Number

HPI

Centers for Medicare and Medicaid Services National Provider Identifier

This qualifier is REQUIRED when the National Provider Identifier is mandated for use and the provider is a covered health care provider under that mandate.

CODE SOURCE 537: Centers for Medicare and Medicaid Services National Provider Identifier

Social Security Number

Federal Taxpayer's Identification Number

Required

127

Reference Identification

O 1

1/50

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

Not Used

352

Description

O 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 CAS segment and
• The payer has a published enumerated healthcare policy code list available to healthcare providers via an un-secure public website and
• The payer wishes to supply this policy detail to reduce provider inquiries.

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

TR3 Notes:

Healthcare Policy - A clinical/statutory rule use to determine claim adjudication that cannot be explained by the sole use of a claim adjustment reason code in the CAS segment and Remittance Advise Remark code when appropriate.
The term Healthcare Policy is intended to include Medical Review Policy, Dental Policy Review, Property and Casualty Policies, Workers Comp Policies and Pharmacy Policies for example Medicare LMRP's.( Local Medicare Review policies) and NCD (National Coverage Determinations).
This policy segment must not be used to provide a proprietary explanation code or reason for adjustment.
Supply the Healthcare policy identifier in REF02 as provided by the payer's published Healthcare policy code list. This policy code will be used to explain the policy used to process the claim which resulted in the adjusted payment.
If this segment is used, the PER (Payer Web Site) segment is required to provide an un-secure WEB contact point where the provider can access the payer's enumerated, published healthcare policy.

TR3 Example:

REF✱0K✱L12345678910~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Policy Form Identifying Number

Required

127

Reference Identification

O 1

1/50

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

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

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.

TR3 Example:

AMT✱B6✱425~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

Allowed - Actual

Allowed amount is the amount the payer deems payable prior to considering patient responsibility.

Deduction Amount

Late Filing Reduction

Tax

Total Claim Before Taxes

Use this monetary amount for the service charge before taxes. This is only used when there is an applicable tax amount on this service.

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

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✱ZL✱3.75~

QTY

✱

✱

✱

✱

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

O 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

O 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: