Remittance A 1 To 5010

Remittance
4010A1
Element Identifier Description ID Min. Max. Usage Reg. Loop Loop Repeat Values Element Identifier Description
5010
ID Min. Max. Usage Reg. Loop Loop Repeat Values
835 4010A1
ISA ISA01 ISA02 ISA03 ISA04 ISA05 ISA06 ISA07 ISA08 ISA09 ISA10 ISA11 ISA12 ISA13 ISA14 ISA15 ISA16 INTERCHANGE CONTROL HEADER Authorization Information Qualifier Authorization Information Security Information Qualifier Security Information Interchange ID Qualifier Interchange Sender ID Interchange ID Qualifier Interchange Receiver ID Interchange Date Interchange Time Interchange Control Standards ID Interchange Control Version Number Interchange Control Number Acknowledgement Requested Usage Indicator Component Element Separator 1 ID 2--2 R R R R R R R R R R R R R R R R R YYMMDD HHMM U 00401 =IEA02 0 P,T 01,14,20,27, 28, 29, 30, 33, ZZ 01,14,20,27, 28, 29, 30, 33, ZZ 00,01 1 00,03 ISA ISA01 ISA02 ISA03 ISA04 ISA05 ISA06 ISA07 ISA08 ISA09 ISA10 ISA11 ISA12 ISA13 ISA14 ISA15 ISA16 INTERCHANGE CONTROL HEADER Authorization Information Qualifier Authorization Information Security Information Qualifier Security Information Interchange ID Qualifier Interchange Sender ID Interchange ID Qualifier Interchange Receiver ID Interchange Date Interchange Time Interchange Control Standards ID Interchange Control Version Number Interchange Control Number Acknowledgement Requested Usage Indicator Component Element Separator
835 5010
1 ID 2--2 R R R R R R R R R R R R R R R R R YYMMDD HHMM U 00401 =IEA02 0 P,T 01,14,20,27, 28, 29, 30, 33, ZZ 01,14,20,27, 28, 29, 30, 33, ZZ 00,01 1 00,03
AN 10--10 ID 2--2
AN 10--10 ID 2--2
AN 10--10 ID 2--2
AN 10--10 ID 2--2
AN 15--15 ID DT TM ID ID N0 ID ID 2--2 6--6 4--4 1--1 5--5 9--9 1--1 1--1 1--1
AN 15--15 ID DT TM ID ID N0 ID ID 2--2 6--6 4--4 1--1 5--5 9--9 1--1 1--1 1--1
AN 15--15
AN 15--15
GS GS01 GS02 GS03 GS04 GS05 GS06 GS07
Functional Group Header Functional Identifier Code Application Sender's Code Application Receiver's Code Date Time Group Control Number Responsible Agency Code Version/Release/Industry Id code Version/Release/Industry Id Code ID AN AN DT TM N0 ID
1 2--2 2--15 2--15 8--8 4--8 1--9 1--2
R R R R R R R R
-----------
1 HP
GS GS01 GS02 GS03 CCYYMMDD HHMM =GE02 X GS04 GS05 GS06 GS07
Functional Group Header Functional Identifier Code Application Sender's Code Application Receiver's Code Date Time Group Control Number Responsible Agency Code ID AN AN DT TM N0 ID
1 2--2 2--15 2--15 8--8 4--8 1--9 1--2
R R R R R R R R
-----------
1 HP
CCYYMMDD HHMM =GE02 X Code Change
GS08 GS08
AN
1--12
004010X091 004010X091A1
GS08
Version Identifier Code
AN
1--12
005010X221
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835 4010A1
ST ST01 ST02 BPR BPR01 Transaction Set Header Transaction Set Identifier Code Transaction Set Control Number Financial Information Transaction Handling Code Total Actual Provider Payment Amt S9(8)V99 Credit or Debit Flag Code Payment Method Code Payment Format Code DFI ID # Qualifier Sender DFI Identifier Acct # Qualifier Sender Bank Acct # Payer Identifier Originating Co Supplemental Code ID 1 ID AN 3--3 4--9 1 1--2 R R R R R ----------1 C,D,H,I,P -----------1 835 =SE02 ST ST01 ST02 BPR BPR01 Transaction Set Header Transaction Set Identifier Code Transaction Set Control Number Financial Information Transaction Handling Code Total Actual Provider Payment Amt S9(9)V99 Credit or Debit Flag Code Payment Method Code Payment Format Code DFI ID # Qualifier Sender DFI Identifier Acct # Qualifier Sender Bank Acct # Payer Identifier Originating Co Supplemental Code
835 5010
1 ID AN 3--3 4--9 1 ID 1--2 R R R R R ----------1 C, D, H, I ,P, U, X Code Added Name Change -----------1 835 =SE02
BPR02 BPR03 BPR04 BPR05 BPR06 BPR07 BPR08 BPR09 BPR10 BPR11 BPR12 BPR13 BPR14 BPR15 BPR16 BPR17 BPR18 BPR19 BPR20 BPR21
R ID ID ID ID AN ID AN
1--18 1--1 3--3 1--10 2--2 3--12 1--3 1--35
R R R S S S S S S S S S S S R N/U N/U N/U N/U N/U DA,SG =TRN03 N/A Medicare 01 DA C ACH,CHK,NON CCP,CTX 01
BPR02 BPR03 BPR04 BPR05 BPR06 BPR07 BPR08 BPR09 BPR10 BPR11 BPR12 BPR13 BPR14 BPR15 BPR16 BPR17 BPR18 BPR19 BPR20 BPR21
R ID ID ID ID AN ID AN
1--18 1--1 3--3 1--10 2--2 3--12 1--3 1--35
R R R S S S S S S S S S S S R N/U N/U N/U N/U N/U DA,SG 01 Logic Change Code Deleted DA C ACH,CHK,NON CCP,CTX 01
AN 10--10 AN 9--9 2--2 3--12 1--3 1--35 8--8 1--3 2--2 3--12 1--3 1--35
AN 10--10 AN 9--9 2--2 3--12 1--3 1--35 8--8 1--3 2--2 3--12 1--3 1--35
DFI ID # Qualifier ID Receiver or Provider Bank ID # AN Acct # Qualifier ID
DFI ID # Qualifier ID Receiver or Provider Bank ID # AN Acct # Qualifier ID
Receiver or Provider Acct # AN Check Issue or EFT Effective Date DT Business Function Code (DFI) ID Number Qualifier (DFI) Identification Number Account Number Qualifier Account Number Reassociation Trace Number Trace Type Code Check or EFT Trace # Payer Identifier Originating Co Supplemental Code Foreign Currency Information ID AN ID ID AN ID AN
Receiver or Provider Acct # AN Check Issue or EFT Effective Date DT Business Function Code (DFI) ID Number Qualifier (DFI) Identification Number Account Number Qualifier Account Number Reassociation Trace Number Trace Type Code Check or EFT Trace # Payer Identifier Originating Company Supplemental Code Foreign Currency Information ID AN ID ID AN ID AN
TRN TRN01 TRN02 TRN03 TRN04
1 1--2 1--30
R R R R S
-----------
1 1 =BPR10 N/A Medicare
TRN TRN01 TRN02 TRN03 TRN04
1 1--2 1--50
R R R R S
-----------
1 1 Increase from 30 - 50 Code Deleted N/U Name Change Code Change
AN 10--10 AN 1--30
AN 10--10 AN 1--30
CUR
-----------
N/A
CUR
-----------
N/A
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835 4010A1
REF REF01 REF02 REF03 REF04 REF REF01 REF02 REF03 REF04 DTM DTM01 DTM02 DTM03 DTM04 DTM05 DTM06 N1 N101 N102 N103 N104 N105 N106 N3 N301 N302 N4 N401 N402 N403 N404 N405 N406 Reference Identification Receiver ID Qualifier Receiver Identifier Description Reference Identifier Version Identification Receiver ID Qualifier Version ID Code Description Reference Identifier Production Date Date Time Qualifier Production Date Time Time Code Date Time Period Format Qualifier Date Time Period Payer Identification Entity Identifier Code Payer Name ID Code Qualifier Payer Identifier Entity Relationship Code Entity Identifier Code Payer Address Payer Address Line Payer Address Line Payer City, State, Zip Payer City Name Payer State Code Payer Postal Zone or ZIP Code Country Code Location Qualifier Location Identifier AN ID ID ID ID AN AN AN ID AN ID AN ID ID ID DT TM ID ID AN 1 3--3 8--8 4--8 2--2 2--3 1--35 1 2--3 1--60 1--2 2--80 2--2 2--3 1 1--55 1--55 1 2--30 2--2 3--15 2--3 1--2 1--30 ID AN AN 1 2--3 1--30 1-80 ID AN AN 1 2--3 1--30 1-80 S R R N/U N/U S R R N/U N/U S R R N/U N/U N/U N/U R R S S S N/U N/U R R S R R R R N/U N/U N/U 1000A 1000A XV 1000A 1 PR ----------1 405 CCYYMMDD ----------1 F2 ----------1 EV REF REF01 REF02 REF03 REF04 REF REF01 REF02 REF03 REF04 DTM DTM01 DTM02 DTM03 DTM04 DTM05 DTM06 N1 N101 N102 N103 N104 N105 N106 N3 N301 N302 N4 N401 N402 N403 N404 N405 N406 N407 Reference Identification Receiver ID Qualifier Receiver Identifier Description Reference Identifier Version Identification Receiver ID Qualifier Version ID Code Description Reference Identifier Production Date Date Time Qualifier Production Date Time Time Code Date Time Period Format Qualifier Date Time Period Payer Identification Entity Identifier Code Payer Name ID Code Qualifier Payer Identifier Entity Relationship Code Entity Identifier Code Payer Address Payer Address Line Payer Address Line Payer City, State, Zip Payer City Name Payer State Code Payer Postal Zone or ZIP Code Country Code Location Qualifier Location Identifier Country Subdivision Code
835 5010
1 ID AN AN 2--3 1--50 1-80 S R R N/U N/U 1 ID AN AN 2--3 1--50 1-80 S R R N/U N/U 1 ID DT TM ID ID AN 3--3 8--8 4--8 2--2 2--3 1--35 1 ID AN ID AN ID ID 2--3 1--60 1--2 2--80 2--2 2--3 1 AN AN 1--55 1--55 1 AN ID ID ID ID AN ID 2--30 2--2 3--15 2--3 1--2 1--30 1--3 S R R N/U N/U N/U N/U R R R S S N/U N/U R R S R R R R N/U N/U N/U S N/U New Element 1000A 1000A XV 1000A 1 PR ----------1 405 CCYYMMDD ----------1 F2 Increase from 30 - 50 ----------1 EV Increase from 30 - 50
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5010
835 4010A1
REF REF01 REF02 REF03 REF04 Additional Payer Identification Reference Identification Qualifier Additional Payer ID Description Reference Identifier 4 ID AN AN 2--3 1--30 1-80 S R R N/U N/U 1000A 2U REF REF01 REF02 REF03 REF04 Additional Payer Identification Reference Identification Qualifier Additional Payer ID Description Reference Identifier Payer Business Contact Information Contact Function Code Payer Contact Name Communication # Qualifier Payer Contact Communication # Communication Number Qualifier 2 Payer Contact Communication # Communication Number Qualifier 3 Payer Contact Communication # Contact Inquiry Reference Payer Technical Contact Information Contact Function Code Payer Contact Name Communication # Qualifier Payer Contact Communication # Communication Number Qualifier 2 Payer Contact Communication # Communication Number Qualifier 3 Payer Contact Communication # Contact Inquiry Reference Payer Web Site Contact Function Code Name Communication # Qualifier
835 5010
4 ID AN AN 2--3 1--50 1-80 S R R N/U N/U Name Change 1 ID AN ID 2--2 1-60 2--2 S R S S S S S S S N/U New Segment >1 ID AN ID 2--2 1-60 2--2 R R S S S S S S S N/U S R N/U R UR 1000A 1C New Segment EM, EX, FX, UR UR EM, TE, UR 1000A BL EX Increase from 80 - 256 AN 1-256 AN 1-20 EM,EX,FX,TE Increase from 80 - 256 AN 1-256 ID 2--2 EM,FX,TE Increase from 80 - 256 AN 1-256 ID 2--2 1000A CX 1000A 2U Increase from 30 - 50
PER PER01 PER02 PER03 PER04 PER05 PER06 PER07 PER08 PER09
Payer Contact Information Contact Function Code Payer Contact Name Communication # Qualifier Payer Contact Communication # Communication Number Qualifier 2 Payer Contact Communication # Communication Number Qualifier 3 Payer Contact Communication # Contact Inquiry Reference ID AN ID AN ID AN ID AN AN
1 2--2 1--60 2--2 1--80 2--2 1--80 2--2 1--80 1-20
S R S S S S S S S N/U
1000A CX EM,FX,TE
PER PER01 PER02 PER03 PER04 EM,EX,FX,TE PER05 PER06 EX PER07 PER08 PER09
PER PER01 PER02 PER03 PER04 PER05 PER06 PER07 PER08 PER09 PER PER01 PER02 PER03
AN 1-256 ID 2--2
AN 1-256 ID 2--2
AN 1-256 AN 1-20 1 ID AN ID 2--2 1-60 2--2
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835 4010A1
PER04 PER05 PER06 PER07 PER08 PER09 N1 N101 N102 N103 N104 N105 N106 N3 N301 N302 Payee Identification Entity Identifier Code Payee Name Identification Code Qualifier Payee ID Code Entity Relationship Code Entity Identifier Code Payee Address Payee Address Line Payee Address Line AN AN ID AN ID AN ID ID 1 2--3 1--60 1--2 2--80 2--2 2--3 1 1--55 1--55 R R S R R N/U N/U S R S 1000B XX 1000B 1 PE N1 N101 N102 N103 N104 N105 N106 N3 N301 N302 Payer Contact Communication # Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Contact Inquiry Reference Payee Identification Entity Identifier Code Payee Name Identification Code Qualifier Payee ID Code Entity Relationship Code Entity Identifier Code Payee Address Payee Address Line Payee Address Line
835 5010
AN 1-256 ID 2--2 R N/U N/U N/U N/U N/U R R R Code Added ID AN ID ID 1--2 2--80 2--2 2--3 1 AN AN 1--55 1--55 R R N/U N/U S R S Usage changed to Required 1000B XX, FI, XV 1000B 1 PE Usage changed to Required AN 1--60
AN 1-256 ID AN 2--2 1-20 1 ID 2--3
AN 1-256
N4 N401 N402 N403 N404 N405 N406
Payee City,State,Zip Payee City Name Payee State Code Payee Postal Zone or ZIP Code Country Code Location Qualifier Location Identifier AN ID ID ID ID AN
1 2--30 2--2 3-15 2--3 1--2 1--30
S R R R S N/U N/U
1000B
N4 N401 N402 N403 N404 N405 N406 N407
Payee City,State,Zip Payee City Name Payee State Code Payee Postal Zone or ZIP Code Country Code Location Qualifier Location Identifier Country Subdivision Code Payee Additional Identification AN ID ID ID ID AN ID
1 2--30 2--2 3-15 2--3 1--2 1--30 1--3
R R S S S N/U N/U S
1000B Usage changed to Situational Usage changed to Situational
New Element
REF
Payee Additional Identification
>1
1000B
REF
>1
1000B
REF01 REF02 REF03 REF04
Reference Identification Qualifier Additional Payee ID # Description Reference Identifier
ID AN AN
2--3 1--30 1-80
R R N/U N/U
TJ
Reference Identification Qualifier Additional Payee ID # Description Reference Identifier
ID AN AN
2--3 1--50 1-80
R R N/U N/U
TJ Increase form 30 - 50
Page 5 of 19
Remittance
4010A1
5010
835 4010A1
RDM RDM01 RDM02 RDM03 RDM04 RDM05 LX LX01 Header Number Assigned # Provider Summary Information Reference Identification Facility Code Value Date Quantity Monetary Amount Monetary Amount Monetary Amount Monetary Amount Monetary Amount Monetary Amount Monetary Amount Monetary Amount Monetary Amount Monetary Amount Monetary Amount Monetary Amount Monetary Amount Monetary Amount Monetary Amount AN AN DT R R R R R R R R R R R R R R R R N0 1 1--6 S R 2000 >1 1,0 LX LX01 Remittance Delivery Method Report Transmission Code Name Communication Number Reference Identifier Reference Identifier Header Number Assigned # Provider Summary Information Provider Identifier Facility Code Value Date Total Claim Count 9(6) Total Claim Change Amount S9(9)V99 Monetary Amount Monetary Amount Monetary Amount Monetary Amount Monetary Amount Monetary Amount Monetary Amount Total MSP Payer Amount S9(9)V99 Monetary Amount Total Non-Lab Charge Amount S9(9)V99 Monetary Amount Total HCPCS Reported Charge Amount S9(9)V99 Total HCPCS Payable Amount S9(9)V99 Monetary Amount
835 5010
New Segment 1 ID AN 1--2 1--60 N/U N/U 1 N0 1--6 S R 2000 >1 TTYYMM Code Change S 1000B BM, EM, FT, OL
AN 1--256
TS3 TS301 TS302 TS303 TS304 TS305 TS306 TS307 TS308 TS309 TS310 TS311 TS312 TS313 TS314 TS315 TS316 TS317 TS318 TS319
1 1--30 1--2 8--8 1--15 1--18 1--18 1--18 1--18 1--18 1--18 1--18 1--18 1--18 1--18 1--18 1--18 1--18 1--18 1--18
S R R R R R S S S S S S S S S S S S S S
2000 NPI POS Code CCYYMMDD
TS3 TS301 TS302 TS303 TS304 TS305 TS306 TS307 TS308 TS309 TS310 TS311 TS312 TS313 TS314 TS315 TS316 TS317 TS318 TS319
1 AN AN DT R R R R R R R R R R R R R R R R 1--60 1--2 8--8 1--15 1--18 1--18 1--18 1--18 1--18 1--18 1--18 1--18 1--18 1--18 1--18 1--18 1--18 1--18 1--18
S R R R R
2000 NPI TT CCYYMMDD Name Change Name Change Increase from 30 - 60 Code Change
R Usage change to Not Used N/U Usage change to Not Used N/U Usage change to Not Used N/U Usage change to Not Used N/U Usage change to Not Used N/U Usage change to Not Used N/U Usage change to Not Used N/U Name Change S Usage change to Not Used N/U Name Change S Usage change to Not Used N/U Name Change S Name Change S Usage change to Not Used N/U
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TS320 TS321 Monetary Amount Monetary Amount R R 1--18 1--18 S S TS320 TS321 Total Professional Component Amount S9(9)V99 Total MSP Patient Liability Met Amount S9(9)V99 Total Patient Reimbursement Amount S9(9)V99 Total PIP Claim Coint 9(6) Total PIP Adjustment Amount S9(9)V99 Provider Supplemental Summary Info Total DRG Amount S9(9)V99 Total Federal Specific Amount Total Hospital Specifc Amount Total Disproportionate Amount Total Capital Amount Total Indirect Medical Education Amount Total Outlier Day Count 9(6) Total Day Outlier Amount Total Cost Outlier Amount Average DRG Length of Stay 9(6) Total Discharge Count 9(6) Total Cost Report Day Count 9(6) Total Covered Day Count 9(6) Total Noncovered Day Count 9(6) Total MSP Pass-Through Amount Average DRG Weight Total PPS Capital FSP DRG Amount Total PSP Capital HSP DRG Amount Total PPS DSH DRG Amount
835 5010
Name Change R R 1--18 1--18 S Name Change S Name Change
TS322 TS323 TS324
Monetary Amount Quantity Monetary Amount Provider Supplemental Summary Info Monetary Amount Monetary Amount Monetary Amount Monetary Amount Monetary Amount Monetary Amount Quantity Monetary Amount Monetary Amount Quantity Quantity Quantity Quantity Quantity Monetary Amount Quantity Monetary Amount Monetary Amount Monetary Amount
R R R
1--18 1--15 1--18
S S S
TS322 TS323 TS324
R R R
1--18 1--15 1--18
S S S Name Change Name Change
TS2 TS201 TS202 TS203 TS204 TS205 TS206 TS207 TS 208 TS 209 TS 210 TS 211 TS212 TS213 TS214 TS215 TS216 TS217 TS218 TS219
1 R R R R R R R R R R R R R R R R R R R 1--18 1--18 1--18 1--18 1--18 1--18 1--15 1--18 1--18 1--15 1--15 1--15 1--15 1--15 1--18 1--15 1--18 1--18 1--18
S S S S S S S S S S S S S S S S S S S S
2000
N/A
TS2 TS201 TS202 TS203 TS204 TS205 TS206 TS207 TS 208 TS 209 TS 210 TS 211 TS212 TS213 TS214 TS215 TS216 TS217 TS218 TS219
1 R R R R R R R R R R R R R R R R R R R 1--18 1--18 1--18 1--18 1--18 1--18 1--15 1--18 1--18 1--15 1--15 1--15 1--15 1--15 1--18 1--15 1--18 1--18 1--18
S S
2000 Name Change Name Change
S Name Change S Name Change S S S Name Change S S S S S S Name Change S Name Change S Name Change S S S Name Change S Name Change S Name Change Name Change Name Change Name Change Name Change Name Change Name Change Name Change Name Change
Page 7 of 19
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835 4010A1
CLP CLP01 Claim Level Data Patient Control # AN 1 1--38 R R 1, 2, 3, 4, 5, 10, 13, 15, 16, 17, 19, 20, 21, 22, 23 2100 >1 CLP CLP01 Claim Level Data Patient Control #
835 5010
1 AN 1--38 R R Code Deleted CLP02 CLP03 CLP04 CLP05 MB CLP06 CLP07 CLP08 N/A Medicare N/A Carriers N/A Carriers N/A Carriers CLP09 CLP10 CLP11 CLP12 CLP13 CLP14 Claim Status Code Total Claim Charge Amount S9(9)V99 Claim Payment Amount S9(9)V99 Patient Responsibility Amount S9(9)V99 Claim Filling Indicator Code Payer Claim Control # Facility Type Code (1st and 2nd position of TOB) Claim Frequency Code (3rd position of TOB) Patient Status Code DRG Code DRG Weight S9(3)V9999 Discharge Fraction S9(4)V999 Yes/No Condition or Response Code Claim Adjustment Claim Adjustment Group Code Adjustment Reason Code Adjustment Amount S9(7)V99 Adjustment Quantity 9(5) Adjustment Reason Code Adjustment Amount S9(7)V99 Adjustment Quantity 9(5) Adjustment Reason Code Adjustment Amount S9(7)V99 Adjustment Quantity 9(5) Adjustment Reason Code Adjustment Amount S9(7)V99 Adjustment Quantity 9(5) Adjustment Reason Code ID R R R ID AN AN ID ID ID R R ID 1--2 1--18 1--18 1--18 1--2 1--50 1--2 1--1 1-2 1--4 1--15 1--10 1--1 99 ID ID R R ID R R ID R R ID R R ID 1--2 1--5 1--18 1--15 1--5 1--18 1--15 1--5 1--18 1--15 1--5 1--18 1--15 1--5 R R Name Change R Name Change S R S S Name Change S N/U S S S New Element N/U S R R R S S S S S S S S S S S New Element New Element New Element New Element New Element CAS12 CAS13 CAS14 New Element New Element New Element CAS09 CAS10 CAS11 Name Change Code Deleted New Element New Element CAS06 CAS07 CAS08 2100 Code Deleted CO, OA, PR Name Change Name Change Name Change MA Code Change Increase from 30 - 50 Name Change 1, 2, 3, 4, 19, 20, 21, 22, 23 Name Change 2100 >1
CLP02 CLP03 CLP04 CLP05 CLP06 CLP07 CLP08 CLP09 CLP10 CLP11 CLP12 CLP13
Claim Status Code Total Claim Charge Amount S9(7)V99 Claim Payment Amount S9(7)V99 Patient Responsibility Amount S9(7)V99 Claim Filling Indicator Code Payer Claim Control # Facility Type Code Claim Frequency Code Patient Status Code DRG Code DRG Weight Discharge Fraction
ID R R R ID AN AN ID ID ID R R
1--2 1--18 1--18 1--18 1--2 1--30 1--2 1--1 1-2 1--4 1--15 1--10
R R R S R S S S N/U S S S
CAS CAS01 CAS02 CAS03 CAS04
Claim Adjustment Claim Adjustment Group Code Adjustment Reason Code Adjustment Amount S9(7)V99 Adjustment Quantity 9(7)
99 ID ID R R 1--2 1--5 1--18 1--15
S R R R S
2100 CO,CR,OA,PR
CAS CAS01 CAS02 CAS03 N/A Medicare CAS04 CAS05
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835 4010A1
CAS15 CAS16 CAS17 CAS18 CAS19 NM1 NM101 NM102 Patient Name Entity Identifier Code Entity Type Qualifier ID ID 1 2--3 1--1 R R R 2100 QC 1 NM1 NM101 NM102 Adjustment Amount S9(7)V99 Adjustment Quantity 9(5) Adjustment Reason Code Adjustment Amount S9(7)V99 Adjustment Quantity 9(5) Patient Name Entity Identifier Code Entity Type Qualifier
835 5010
New Element R R ID R R 1--18 1--15 1--5 1--18 1--15 1 ID ID 2--3 1--1 S S S S S R R R 2100 QC 1 Increase from 35 - 60 Usage change to Situational Increase from 25 - 35 Usage change to Situational New Element New Element New Element New Element
NM103
Patient Last Name
AN
1--35
NM103
Patient Last Name
AN
1--60
NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111
Patient First Name Patient Middle Name Name Prefix Patient Name Suffix ID Code Qualifier Patient Identifier Entity Relationship Code Entity Identifier Code
AN AN AN AN ID AN ID ID
1--25 1--25 1-10 1--10 1--2 2--80 2--2 2--3
R S N/U S S S N/U N/U HN,II, MI
NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111 NM112
Patient First Name Patient Middle Name Name Prefix Patient Name Suffix ID Code Qualifier Patient Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name Insured's Name Corrected Patient/Insured Name Entity Identifier Code Entity Type Qualifier Corrected Patient/Ins Last Name Corrected Patient/Ins First Name Corrected Patient/Ins Middle Name Name Prefix Corrected Patient Name Suffix Identification Code Qualifier Corrected Ins Identification Indicator Entity Relationship Code
AN AN AN AN ID AN ID ID AN
1--35 1--25 1-10 1--10 1--2 2--80 2--2 2--3 1--60 1
S S N/U S S S N/U N/U N/U HN HIC #
Code Added Code Deleted Code Added
New Element N/U S 2100 N/A
NM1
Insured's Name Corrected Patient/Insured Name Entity Identifier Code Entity Type Qualifier Corrected Patient/Ins Last Name Corrected Patient/Ins First Name Corrected Patient/Ins Middle Name Name Prefix Corrected Patient Name Suffix Identification Code Qualifier Corrected Ins Identification Indicator Entity Relationship Code ID ID AN AN AN AN AN ID AN ID
2100
N/A
NM1
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110
1 2--3 1--1 1--35 1--25 1--25 1-10 1--10 1--2 2--80 2--2
S R R S S S N/U S S S N/U
2100 74 1
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 C NM108 NM109 NM110
1 ID ID AN AN AN AN AN ID AN ID 2--3 1--1 1--60 1--35 1--25 1-10 1--10 1--2 2--80 2--2
S R R S
2100 74 1 Increase from 35 - 60 Increase from 25 - 35
S S N/U S S S N/U C
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NM111 Entity Identifier Code ID 2--3 N/U NM111 NM112 NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111 Service Provider Name Entity Identifier Code Entity Type Qualifier Rendering Provider Last/Org Name Rendering Provider First Name Rendering Provider Middle Name Name Prefix Rendering Provider Name Suffix ID Code Qualifier Rendering Provider Identifier Entity Relationship Code Entity Identifier Code ID ID AN AN AN AN AN ID AN ID ID 1 2--3 1--1 1-35 1--25 1--25 1-10 1--10 1--2 2--80 2--2 2--3 S R R S S S N/U S R R N/U N/U N/A Medicare XX 2100 82 1, 2 N/A Medicare N/A Medicare N/A Medicare NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111 NM112 Entity Identifier Code Name Last or Organization Name Service Provider Name Entity Identifier Code Entity Type Qualifier Rendering Provider Last/Org Name Rendering Provider First Name Rendering Provider Middle Name Name Prefix Rendering Provider Name Suffix ID Code Qualifier Rendering Provider Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name
835 5010
ID AN 2--3 1--60 1 ID ID AN AN AN AN AN ID AN ID ID AN 2--3 1--1 1-60 1-35 1--25 1-10 1--10 1--2 2--80 2--2 2--3 1--60 N/U New Element N/U S R R S S S N/U S R R N/U N/U New Element N/U NA NA NA NA XX Code Added NPI Code Added Code Change 2100 82 2 Code Deleted Increase from 35 - 60 Code Deleted Increase from 25 - 35 Code Change Code Change
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111
Crossover Carrier Name Entity Identifier Code Entity Type Qualifier COB Carrier Name First name Middle name Not Used name suffix ID Code Qualifier COB Carrier Identifier Entity Relationship Code Entity Identifier Code ID ID AN AN AN AN AN ID AN ID ID
1 2--3 1--1 1--35 1-25 1-25 1-10 1-10 1--2 2--80 2--2 2--3
S R R R N/U N/U N/U N/U R R N/U N/U
2100 TT 2
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107 PI,XV NM108 NM109 NM110 NM111 NM112
Crossover Carrier Name Entity Identifier Code Entity Type Qualifier COB Carrier Name First name Middle name Name Prefix Name suffix ID Code Qualifier COB Carrier Identifier Entity Relationship Code Entity Identifier Code Name Last or Organization Name Corrected Priority Payer Name Entity Identifier Code Entity Type Qualifier Corrected Priority Payer Name ID ID AN ID ID AN AN AN AN AN ID AN ID ID AN
1 2--3 1--1 1-60 1-35 1-25 1-10 1-10 1--2 2--80 2--2 2--3 1--60
S R R R N/U N/U N/U N/U R R N/U N/U
2100 TT 2 Increase from 35 - 60 Increase from 25 - 35
PI,XV
New Element N/U # Repeats change to 1 1 2--3 1--1 1--60 S R R R 2100 PR 2 Increase from 35 - 60
NM1 NM101 NM102 NM103
Corrected Priority Payer Name Entity Identifier Code Entity Type Qualifier Corrected Priority Payer Name ID ID AN
2 2--3 1--1 1--35
S R R R
2100 PR 2
NM1 NM101 NM102 NM103
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NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111 First name middle name Name Prefix name suffix ID Code Qualifier Corrected Priority Payer ID Entity Relationship Code Entity Identifier Code AN AN AN AN ID AN ID ID 1--25 1--25 1-10 1--10 1--2 2--80 2--2 2--3 N/U N/U N/U N/U R R N/U N/U PI,XV NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111 NM112 NM1 Inpatient Adjudication Information Quantity Quantity Quantity Monetary Amount Reference Identification Monetary Amount Monetary Amount Monetary Amount Monetary Amount Monetary Amount Monetary Amount Monetary Amount Monetary Amount Monetary Amount Quantity Monetary Amount R R R R AN R R R R R R R R R R R First name middle name Name Prefix Name suffix ID Code Qualifier Corrected Priority Payer ID Entity Relationship Code Entity Identifier Code Name Last or Organization Name Other Subscriber Name
835 5010
AN AN AN AN ID AN ID ID AN 1-35 1-25 1-10 1-10 1--2 2--80 2--2 2--3 1--60 N/U N/U N/U N/U R R N/U N/U New Element N/U N/A New Segment PI,XV Increase from 25 - 35
MIA MIA01 MIA02 MIA03 MIA04 MIA05 MIA06 MIA07 MIA08 MIA09 MIA10 MIA11 MIA12 MIA13 MIA14 MIA15 MIA16
1 1--15 1--15 1--15 1--18 1--30 1--18 1--18 1--18 1--18 1--18 1--18 1--18 1--18 1--18 1--15 1--18
S R S S S S S S S S S S S S S S S
2100
N/A
MIA MIA01 MIA02 MIA03 MIA04 MIA05 MIA06 MIA07 MIA08 MIA09 MIA10 MIA11 MIA12 MIA13 MIA14 MIA15 MIA16
Inpatient Adjudication Information Covered Daya or Visits Count S(9)3 R PPS Operating Outlier Amount S9(7)V99 R Lifetime Psychiatric Days Count S9(3) R CLAIM DRG AMOUNT S9(7)V99 R CLAIM PAYMENT REMARK CD AN CLAIM DSH AMOUNT S9(7)V99 R CLAIM MSP PASS THRU AMT S9(7)V99 R CLAIM PPS CAPITAL AMOUNT S9(7)V99 R PPS CAPITAL FSP DRG AMT S9(7)V99 R PPS CAPITAL HSP DRG AMT S9(7)V99 R PPS CAPITAL DSH DRG AMT S9(7)V99 R OLD CAPITAL AMOUNT S9(7)V99 R PPS CAPITAL IME AMOUNT S9(7)V99 R PPS OPER HSP SPEC DRG AMT S9(7)V99 R COST REPORT DAY COUNT S(9)3 R PPS OPER FSP SPEC DRG AMT S9(7)V99 R
1 1--15 1--18 1--15 1--18 1--50 1--18 1--18 1--18 1--18 1--18 1--18 1--18 1--18 1--18 1--15 1--18
S R S S
2100 Name Change Name Change Increase from 15 - 18 Name Change Name Change
S S S Name Change S Name Change S Name Change S Name Change S Name Change S Name Change S Name Change S Name Change S Name Change S Name Change S Name Change Increase from 30 - 50 Name Change
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MIA17 MIA18 MIA19 MIA20 MIA21 MIA22 MIA23 MIA24 Monetary Amount Monetary Amount Monetary Amount Reference Identification Reference Identification Reference Identification Reference Identification Monetary Amount Outpatient Adjudication Information Reimbursement Rate 9(3)V99 Claim HCPCS Payable Amount S9(7)V99 Remark Code Remark Code Remark Code Remark Code Remark Code Claim ESRD Payment Amount S9(7)V99 Nonpayable Professional Comp Amt S9(7)V99 Other Claim-Related Identification R R AN AN AN AN AN R R R R R AN AN AN AN R 1--18 1--18 1--18 1--30 1--30 1--30 1--30 1--18 S S S S S S S S MIA17 MIA18 MIA19 MIA20 MIA21 MIA22 MIA23 MIA24 CLAIM PPS OUTLIER AMOUNT S9(7)V99 CLAIM INDIRECT TEACHING S9(7)V99 NON PAY PROF COMP AMT S9(7)V99 CLAIM PAYMENT REMARK CD CLAIM PAYMENT REMARK CD CLAIM PAYMENT REMARK CD CLAIM PAYMENT REMARK CD PPS CAPITAL EXCEPTION AMT S9(7)V99 Outpatient Adjudication Information Reimbursement Rate S9(4)V9999 Claim HCPCS Payable Amount S9(7)V99 Remark Code Remark Code Remark Code Remark Code Remark Code Claim ESRD Payment Amount S9(7)V99 Nonpayable Professional Comp Amt S9(7)V99 Other Claim-Related Identification
835 5010
Name Change R R R AN AN AN AN R 1--18 1--18 1--18 1--50 1--50 1--50 1--50 1--18 S Name Change S Name Change S S S S S S Name Change Increase from 30 - 50 Name Change Increase from 30 - 50 Name Change Increase from 30 - 50 Name Change Increase from 30 - 50 Name Change
MOA MOA01 MOA02 MOA03 MOA04 MOA05 MOA06 MOA07 MOA08 MOA09
1 1--10 1--18 1--30 1--30 1--30 1--30 1--30 1--18 1--18
S S S S S S S S S S
2100 N/A Carriers N/A Carriers
MOA MOA01 MOA02 MOA03 MOA04 MOA05 MOA06 MOA07 N/A Carriers N/A Carriers MOA08 MOA09
1 R R AN AN AN AN AN R R 1--10 1--18 1--50 1--50 1--50 1--50 1--50 1--18 1--18
S S S S S S S S S
2100 Name Change Code Deleted Code Deleted Increase from 30 - 5-0 Increase from 30 - 5-0 Increase from 30 - 5-0 Increase from 30 - 5-0 Increase from 30 - 5-0 Code Deleted Code Deleted
REF
2100
N/A 1L, 1W, 9A, 9C, A6, BB, CE, EA, F8, G1, G3, IG, SY
REF
2100 Code Change
Reference Identification Qualifier
ID
2--3 1--30 1-80
R R N/U N/U
Reference Identification Qualifier
ID
2--3 1--50 1-80
R R N/U N/U
EA, 6P, 28 Increase from 30 - 50
Other Claim Related Identifier AN Description Reference Identifier Rendering Provider Identification Reference Identification Qualifier AN
Other Claim Related Identifier AN Description Reference Identifier Rendering Provider Identification Reference Identification Qualifier AN
New Segment 10 ID 2--3 S R 2100 Code Deleted
REF REF01
10 ID 2--3
S R
2100
N/A 1A, 1B, 1C, 1D, 1G, 1H, D3, G2
REF REF01
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REF02 REF03 REF04 DTM DTM01 DTM02 DTM03 DTM04 DTM05 DTM06 Rendering Provider Secondary Identifier Description Reference Identifier Claim Payment Date Date Time Qualifier Claim Date Time Time Code Date Time Period Format Qualifier Date Time Period ID DT TM ID ID AN 4 3--3 8--8 4--8 2--2 2--3 1--35 AN AN 1--30 1-80 R N/U N/U S R R N/U N/U N/U N/U 2100 050 CCYYMMDD REF02 REF03 REF04 Rendering Provider Secondary Identifier Description Reference Identifier
835 5010
Increase from 30 - 50 AN AN 1--50 1-80 R N/U N/U Segment Deleted
New Segment DTM DTM01 DTM02 DTM03 DTM04 DTM05 DTM06 Statement From or To Date Date Time Qualifier Claim Date Time Time Code Date Time Period Format Qualifier Date Time Period ID DT TM ID ID AN 2 3--3 8--8 4--8 2--2 2--3 1--35 S R R N/U N/U N/U N/U New Segment DTM DTM01 DTM02 DTM03 DTM04 DTM05 DTM06 DTM DTM01 DTM02 DTM03 DTM04 DTM05 DTM06 Coverage Expiration Date Date/Time Qualifier Date Time Time Code Date Time Period Format Qualifier Date Time Period Claim Received Date Date/Time Qualifier Date Time Time Code Date Time Period Format Qualifier Date Time Period ID DT TM ID ID AN ID DT TM ID ID AN 1 3--3 8--8 4--8 2--2 2--3 1--35 1 3--3 8--8 4--8 2--2 2--3 1--35 S R R N/U N/U N/U N/U S R R N/U N/U N/U N/U # Repeats change to 2 PER Claim Contact Information 3 S 2100 PER Claim Contact Information 2 S 2100 2100 050 CCYYMMDD New Segment 2100 N/A 2100 050 CCYYMMDD
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PER01 PER02 PER03 Contact Function Code Claim Contact Name Communication # Qualifier ID AN ID 2--2 1--60 2--2 R S S EM,FX,TE CX PER01 PER02 PER03 Contact Function Code Claim Contact Name Communication # Qualifier
835 5010
ID AN ID 2--2 1--60 2--2 R S Usage change to Required R EM,FX,TE Increase from 80 - 256 Usage change to Required R S S S S N/U # Repeats change to 13 13 ID R ID 1--3 1--18 1--1 S R R N/U # Repeats change to 14 14 S 2100 Code Deleted CA, CD, LA, OU ZK, ZL 2100 AU, DY, F5, I, NL, Code Added ZK, ZL EX Increase from 80 - 256 EM,EX,FX,TE Increase from 80 - 256 CX
PER04 PER05 PER06 PER07 PER08 PER09
Claim Contact Communication # AN Communication # Qualifier ID Claim Contact Communication # AN Communication # Qualifier Communication # Extension Contact Inquiry Reference Claim Supplemental Information Amount Qualifier Code Claim Supplemental Information Amt S9(7)V99 Credit/Debit Flag Code Claim Supplemental Infor Quantity ID R ID ID AN AN
1--80 2--2 1--80 2--2 1--80 1--20
S S S S S N/U EX EM,EX,FX,TE
PER04 PER05 PER06 PER07 PER08 PER09
Claim Contact Communication # AN 1--256 Communication # Qualifier ID 2--2 Claim Contact Communication # AN 1--256 Communication # Qualifier Communication # Extension Contact Inquiry Reference Claim Supplemental Information Amount Qualifier Code Claim Supplemental Information Amt S9(7)V99 Credit/Debit Flag Code Claim Supplemental Infor Quantity ID 2--2
AN 1--256 AN 1--20
AMT AMT01 AMT02 AMT03
14 1--3 1--18 1--1
S R R N/U
2100 F5,I
QTY
15
2100
N/A CA, CD, LA, LE, NA, NE, NR, OU, PS, VS, ZK, ZL, ZM, ZN, ZO
QTY
QTY01 QTY02 QTY03 QTY04 SVC
Quantity Qualifier Quantity Qualifier Composite Unit Of Measure Free-Form Message
ID R
2--2 1--15
R R N/U
QTY01 QTY02 QTY03 QTY04
Quantity Qualifier Quantity Qualifier Composite Unit Of Measure Free-formInformation
ID R
2--2 1--15
R R N/U
AN
1--30 1
N/U S R 2110 999
AN
1--30 1
N/U S R Code Aded 2110 999
Service Payment Information Composite Medical Procedure Identifier SVC01 Product or Service ID Qualifier -01-1 ID -01-2 -01-3 -01-4 -01-5 -01-6 Procedure Code Procedure Modifier Procedure Modifier Procedure Modifier Procedure Modifier AN AN AN AN AN AN
2--2 1--48 2--2 2--2 2--2 2--2 1--80
R R S S S S S
HC,N4
Service Payment Information Composite Medical Procedure Identifier SVC01 Product or Service ID Qualifier SVC01-1 ID SVC SVC01-2 Adjudicated Procedure Code SVC01-3 SVC01-4 SVC01-5 SVC01-6 Procedure Modifier Procedure Modifier Procedure Modifier Procedure Modifier Description AN AN AN AN AN AN
2--2 1--48 2--2 2--2 2--2 2--2 1--80
R R S S S S
HC, HP, N4, N/U
Usage change to Not Used -01-7 Procedure Code Description N/A Medicare SVC01-7 N/U
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SVC01-8 Line Item Charge Amount S9(7)V99 SVC02 Line Item Provider Payment S9(7)V99 SVC03 SVC04 NUBC Revenue Code R R AN 1--18 1--18 1--48 R R S N/A Carriers SVC02 SVC03 SVC04 Product/Service ID Line Item Charge Amount S9(7)V99 Line Item Provider Payment S9(7)V99 N/UBC Revenue Code
835 5010
AN R R AN 1--48 1--18 1--18 1--48 N/U R R S Code Deleted Name Change New Element
SVC01-1=N4 Units of Service Paid Count S9(7)V999 SVC01-1 = HC Units of Service Paid Count S9(3)V9 SVC05 R Composite Medical Procedure Identifier SVC06 Product or Service ID Qualifier -06-1 ID -06-2 -06-3 -06-4 -06-5 -06-6 Procedure Code Procedure Modifier Procedure Modifier Procedure Modifier Procedure Modifier AN AN AN AN AN AN
1--15
S S
SVC05
2--2 1--48 2--2 2--2 2--2 2--2 1--80
R R S S S S S
HC,N4
Units of Service Paid Count S9(6) R Composite Medical Procedure Identifier SVC06 Product or Service ID Qualifier SVC06-1 ID SVC06-2 SVC06-3 SVC06-4 SVC06-5 SVC06-6 Procedure Code Procedure Modifier Procedure Modifier Procedure Modifier Procedure Modifier Procedure Code Description Product/Service ID AN AN AN AN AN AN AN
1--15
S S Code Added
2--2 1--48 2--2 2--2 2--2 2--2 1--80 1--48
R R S S S S S N/U
HC, HP, N4, N/U
-06-7 Procedure Code Description
N/A Medicare
SVC06-7 SVC06-8
New Element Name Change
SVC07
SVC06-1=N4 Units of Service Original Count S9(7)V999 SVC06-1 = HC Units of Service Original Count S9(7)V9 Service Date Time Reference Date Time Qualifier Claim Date Time Time Code Date Time Period Format Qualifier Date Time Period Service Adjustment Claim Adjustment Group Code Adjustment Reason Code Adjustment Amount S9(7)V99
1--15
SVC07
Original Units of Service Count S9(6)
1--15
S # Repeats change to 2
DTM DTM01 DTM02 DTM03 DTM04 DTM05 DTM06 CAS CAS01 CAS02 CAS03
3 ID DT TM ID ID AN 3--3 8--8 4--8 2--2 2--3 1--35 99 ID ID R 1--2 1--5 1--18
S R R N/U N/U N/U N/U S R R R
2110 150,151,472 CCYYMMDD
DTM DTM01 DTM02 DTM03 DTM04 DTM05 DTM06
Service Date Date Time Qualifier Service Date Time Time Code Date Time Period Format Qualifier Date Time Period Service Adjustment Claim Adjustment Group Code Adjustment Reason Code Adjustment Amount S9(7)V99 ID DT TM ID ID AN
2 3--3 8--8 4--8 2--2 2--3 1--35 99 ID ID R 1--2 1--5 1--18
S R R N/U N/U N/U N/U S R R R
2110 472 CCYYMMDD Code Deleted
2110 CO,CR,OA,PR
CAS CAS01 CAS02 CAS03
2110 Code Deleted CO,OA,PR
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CAS04 CAS05 CAS06 CAS07 CAS08 CAS09 CAS10 CAS11 CAS12 CAS13 CAS14 CAS15 CAS16 CAS17 CAS18 CAS19 REF REF01 REF02 REF03 REF04 Adjustment Quantity 9(7) Adjustment Reason Code Adjustment Amount S9(7)V99 Adjustment Quantity 9(7) Adjustment Reason Code Adjustment Amount S9(7)V99 Adjustment Quantity 9(7) Adjustment Reason Code Adjustment Amount S9(7)V99 Adjustment Quantity 9(7) Adjustment Reason Code Adjustment Amount S9(7)V99 Adjustment Quantity 9(7) Adjustment Reason Code Adjustment Amount S9(7)V99 Adjustment Quantity 9(7) Service Identification Reference ID Qualifier Provider ID Description Reference Identifier ID AN AN R ID R R ID R R ID R R ID R R ID R R 1--15 1--5 1--18 1--15 1--5 1--18 1--15 1--5 1--18 1--15 1--5 1--18 1--15 1--5 1--18 1--15 7 2--3 1--30 1-80 S S S S S S S S S S S S S S S S S R R N/U N/U 2110 LU,6R N/A Medicare N/A Medicare N/A Medicare N/A Medicare N/A Medicare N/A Medicare CAS04 CAS05 CAS06 CAS07 CAS08 CAS09 CAS10 CAS11 CAS12 CAS13 CAS14 CAS15 CAS16 CAS17 CAS18 CAS19 REF REF01 REF02 REF03 REF04 Adjustment Quantity S9(5) Adjustment Reason Code Adjustment Amount S9(7)V99 Adjustment Quantity S9(5) Adjustment Reason Code Adjustment Amount S9(7)V99 Adjustment Quantity S9(5) Adjustment Reason Code Adjustment Amount S9(7)V99 Adjustment Quantity S9(5) Adjustment Reason Code Adjustment Amount S9(7)V99 Adjustment Quantity S9(5) Adjustment Reason Code Adjustment Amount S9(7)V99 Adjustment Quantity S9(5) Service Identification Reference ID Qualifier Provider ID Description Reference Identifier
835 5010
R ID R R ID R R ID R R ID R R ID R R 1--15 1--5 1--18 1--15 1--5 1--18 1--15 1--5 1--18 1--15 1--5 1--18 1--15 1--5 1--18 1--15 8 ID AN AN 2--3 1--50 1-80 S S S S S S S S S S S S S S S S S R R N/U N/U New Segment REF REF01 REF02 REF03 REF04 Line Item Control Number 1 ID AN AN 2--3 1--50 1-80 S R R N/U N/U 2110 2110 LU Code Deleted Name Change # Repeats change to 8 Code Deleted Increase from 30 - 50 Code Deleted Name Change Code Deleted Name Change Code Deleted Name Change Code Deleted Name Change Code Deleted Name Change
Reference ID Qualifier
Line Item Control Number Description Reference Identifier Rendering Provider Information Reference ID Qualifier Rendering Provider ID Description Reference Identifier
REF REF01 REF02 REF03 REF04
Rendering Provider Information Reference ID Qualifier Rendering Provider ID Description Reference Identifier ID AN AN
10 2--3 1--30 1-80
S R R N/U N/U
2110 HPI
REF REF01 REF02 REF03 REF04
10 ID AN AN 2--3 1--50 1-80
S R R N/U N/U
2110 HPI Increase from 30 - 50
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REF REF01 REF02 REF03 REF04 Service Supplemental Amount Amount Qualifier Code ID Service Supplemental Amount S9(7)V99 R Credit/Debit Flag Code Service Supplemental Quantity Quantity Qualifier Quantity Composite Unit Of Measure Free-Form Message AN 1--30 ID R ID Health Care Policy Identification Reference ID Qualifier Healthcare Policy ID Description Reference Identifier Service Supplemental Amount
835 5010
New Segment 5 ID AN AN 2--3 1--50 1-80 S R R N/U N/U # Repeats change to 9 9 1--3 1--18 1--1 S R R N/U 2110 B6, KH 2110 0K
12 1--3 1--18 1--1
S R R N/U
2110 B6,KH
Amount Qualifier Code ID Service Supplemental Amount S9(7)V99 R Credit/Debit Flag Code Service Supplemental Quantity Quantity Qualifier Service Supplemental Quantity Count Composite Unit Of Measure Free-formInformation AN ID R ID
QTY QTY01 QTY02 QTY03 QTY04
6 2--2 1--15
S R R N/U N/U
2110
N/A NE, ZK, ZL, ZM, ZN, ZO
QTY QTY01 QTY02 QTY03 QTY04
6 2--2 1--15
S R
2110 Code Deleted Name Change
R N/U
1--30
N/U
LQ LQ01 LQ02
Health Care Remarks Codes Code List Qualifier Code Remark Code ID AN
99 1--3 1--30
S R R
2110 HE
LQ LQ01 LQ02
Health Care Remarks Codes Code List Qualifier Code Remark Code ID AN
99 1--3 1--30
S R R
2110 HE
PLB PLB-01 PLB02 PLB03
Provider Level Adjustment Provider Identifier Fiscal Period Date Adjustment Identifier AN DT
>1 1--30 8--8
S R R R
-------
1 NPI CCYYMMDD CS, AP, FB, LE, L6, 50, SL, WO, B2, IR, 72, J1
PLB PLB-01 PLB02 PLB03
Provider Level Adjustment Provider Identifier Fiscal Period Date Adjustment Identifier AN DT
>1 1--50 8--8
S R R R
-------
1 NPI CCYYMMDD CS, AP, FB, LE, L6, 50, Sl, WO, B2, IR, 72, J1 Increase from 30 - 50 Increase from 30 - 50
-03-1
Adjustment Reason Code
ID
2--2 1--30 1--18
R S R S
PLB03-1
ID
2--2 1--50 1--18
R S R S
-03-2 Provider Adjustment Identifier AN Provider Adjustment Amount S9(7)V99 PLB04 R PLB05 Adjustment Identifier
PLB03-2 Provider Adjustment Identifier AN Provider Adjustment Amount S9(7)V99 PLB04 R PLB05 CS, AP, FB, LE, L6, 50, SL, WO, B2, IR, 72, J1 Adjustment Identifier
-05-1
ID
2--2 1--30
R S
PLB05-1
ID
2--2 1--50
R S
CS, AP, FB, LE, L6, 50, Sl, WO, B2, IR, 72, J1 Increase from 30 - 50
-05-2 Provider Adjustment Identifier AN
PLB05-2 Provider Adjustment Identifier AN
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PLB06 PLB07 Provider Adjustment Amount S9(7)V99 Adjustment Identifier R 1--18 S S CS, AP, FB, LE, L6, 50, SL, WO, B2, IR, 72, J1 PLB06 PLB07 Provider Adjustment Amount S9(7)V99 Adjustment Identifier
835 5010
R 1--18 S S CS, AP, FB, LE, L6, 50, Sl, WO, B2, IR, 72, J1 Increase from 30 - 50
-07-1
ID
2--2 1--30 1--18
R S S S
PLB07-1
ID
2--2 1--50 1--18
R S S S
-09-1
ID
2--2 1--30 1--18
R S S S
PLB09-1
ID
2--2 1--50 1--18
R S S S
-11-1
ID
2--2 1--30 1--18
R S S S
PLB11-1
ID
2--2 1--50 1--18
R S S S
-13-1
ID
2--2 1--30 1--18 1
R S S R R R ---1
PLB13-1
ID
2--2 1--50 1--18 1
R S S R R R ---1
CS, AP, FB, LE, L6, 50, SL, WO, B2, IR, 72, J1 Increase from 30 - 50
-13-2 Provider Adjustment Identifier AN Provider Adjustment Amount S9(7)V99 PLB14 R SE SE01 SE02 Transition Set Trailer Transition Segment Count Transition Set Control # N0 AN
PLB13-2 Provider Adjustment Identifier AN Provider Adjustment Amount S9(7)V99 PLB14 R SE SE01 =ST02 SE02 Transition Set Trailer Transition Segment Count Transition Set Control # N0 AN
1--10 4--9
1--10 4--9
=ST02
GE GE01 GE02
Functional Group Trailer # Transaction Sets Included Group Control # N0 N0
1 1-6 1-9
R R R
---
GE GE01 GE02
Functional Group Trailer # Transaction Sets Included Group Control # N0 N0
1 1-6 1-9
R R R
---
IEA
Interchange Control Trailer
----
IEA
Interchange Control Trailer
----
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IEA01 IEA02 # Included Functional Groups Interchange Control # N0 N0 1-5 9-9 R R IEA01 IEA02 # Included Functional Groups Interchange Control #
835 5010
N0 N0 1-5 9-9 R R
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Remittance

GS GS01 GS02 GS03 GS04 GS05 GS06 GS07

1 2--2 2--15 2--15 8--8 4--8 1--9 1--2

1 2--2 2--15 2--15 8--8 4--8 1--9 1--2

CCYYMMDD HHMM =GE02 X Code Change

Version Identifier Code

1--18 1--1 3--3 1--10 2--2 3--12 1--3 1--35

1--18 1--1 3--3 1--10 2--2 3--12 1--3 1--35

DFI ID # Qualifier ID Receiver or Provider Bank ID # AN Acct # Qualifier ID

DFI ID # Qualifier ID Receiver or Provider Bank ID # AN Acct # Qualifier ID

TRN TRN01 TRN02 TRN03 TRN04

1 1 =BPR10 N/A Medicare

TRN TRN01 TRN02 TRN03 TRN04

1 1 Increase from 30 - 50 Code Deleted N/U Name Change Code Change

1 2--2 1--60 2--2 1--80 2--2 1--80 2--2 1--80 1-20

AN 1-256 AN 1-20 1 ID AN ID 2--2 1-60 2--2

AN 1-256 ID AN 2--2 1-20 1 ID 2--3

N4 N401 N402 N403 N404 N405 N406

1 2--30 2--2 3-15 2--3 1--2 1--30

N4 N401 N402 N403 N404 N405 N406 N407

1 2--30 2--2 3-15 2--3 1--2 1--30 1--3

1000B Usage changed to Situational Usage changed to Situational

Payee Additional Identification

REF01 REF02 REF03 REF04

Reference Identification Qualifier Additional Payee ID # Description Reference Identifier

2--3 1--30 1-80

REF01 REF02 REF03 REF04

Reference Identification Qualifier Additional Payee ID # Description Reference Identifier

2--3 1--50 1-80

2000 NPI POS Code CCYYMMDD

TS322 TS323 TS324

1--18 1--15 1--18

TS322 TS323 TS324

1--18 1--15 1--18

S S S Name Change Name Change

2000 Name Change Name Change

CAS CAS01 CAS02 CAS03 CAS04

99 ID ID R R 1--2 1--5 1--18 1--15

CAS CAS01 CAS02 CAS03 N/A Medicare CAS04 CAS05

Patient Last Name

Patient Last Name

NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111

1--25 1--25 1-10 1--10 1--2 2--80 2--2 2--3

R S N/U S S S N/U N/U HN,II, MI

NM104 NM105 NM106 NM107 NM108 NM109 NM110 NM111 NM112

1--35 1--25 1-10 1--10 1--2 2--80 2--2 2--3 1--60 1

S S N/U S S S N/U N/U N/U HN HIC #

Code Added Code Deleted Code Added

New Element N/U S 2100 N/A

2100 74 1 Increase from 35 - 60 Increase from 25 - 35

S R R R N/U N/U N/U N/U R R N/U N/U

S R R R N/U N/U N/U N/U R R N/U N/U

2100 TT 2 Increase from 35 - 60 Increase from 25 - 35

NM1 NM101 NM102 NM103

2 2--3 1--1 1--35

NM1 NM101 NM102 NM103

1 1--10 1--18 1--30 1--30 1--30 1--30 1--30 1--18 1--18

2100 N/A Carriers N/A Carriers

1 R R AN AN AN AN AN R R 1--10 1--18 1--50 1--50 1--50 1--50 1--50 1--18 1--18

2100 Code Change

REF01 REF02 REF03 REF04

Reference Identification Qualifier