835 Health Care Claim Payment/Advice (X221A1)
Health Partner Plans · X12 005010X221A1
Health Partner Plans’ published 835 specification, rendered as an interactive guide. Expand any segment to see its elements, data types, lengths and accepted codes — then validate your own document against it below.
Specification
53 of 53 segments
HEADING
ST
Transaction Set Header
pos 0100
Optional
max —
BPR
Financial Information
- Use the BPR to address a single payment to a single payee. A payee may represent a single provider, a provider group, or multiple providers in a chain. The BPR contains mandatory information, even when it is not being used to move funds electronically.
pos 0200
Required
max —
TRN
Reassociation Trace Number
- This segment's purpose is to uniquely identify this transaction set and to aid in reassociating payments and remittances that have been separated.
pos 0400
Required
max —
CUR
Foreign Currency Information
- When the CUR segment is not present, the currency of payment is defined as US dollars.
- Required when the payment is not being made in US dollars. If not required by this implementation guide, do not send.
pos 0500
Optional
max —
REF
Receiver Identificationvariant 1 of 2
- This is the business identification information for the transaction receiver. This may be different than the EDI address or identifier of the receiver. This is the initial receiver of the transaction. This information must not be updated if the transaction is routed through multiple intermediaries, such as clearinghouses, before reaching the payee.
- Required when the receiver of the transaction is other than the payee (e.g., a clearinghouse or billing service). If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
pos 0600
Optional
max —
REF
Version Identificationvariant 2 of 2
- Update this reference number whenever a change in the version or release number affects the 835. (This is not the ANSI ASCX12 version number as reported in the GS segment.)
- Required when necessary to report the version number of the adjudication system that generated the claim payments in order for the payer to resolve customer service questions from the payee. If not required by this implementation guide, do not send.
pos 0600
Optional
max —
DTM
Production Date
- If your adjudication cycle completed on Thursday and your 835 is produced on Saturday, you are required to populate this segment with Thursday's date.
- Required when the cut off date of the adjudication system remittance run is different from the date of the 835 as identified in the related GS04 element. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
pos 0700
Optional
max —
1000A LoopPayer Identification Looprequired
N1
Payer Identification
- 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.
pos 0800
Required
max —
N3
Payer Address
pos 1000
Required
max —
N4
Payer City, State, ZIP Code
pos 1100
Required
max —
REF
Additional Payer Identification
- The ID available in the TRN and N1 segments must be used before using the REF segment.
- 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.
pos 1200
Optional
max 4
PER
Payer Business Contact Informationvariant 1 of 3
- 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.
- 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.
pos 1300
Optional
max —
PER
Payer Technical Contact Informationvariant 2 of 3
- Required to report technical contact information for this remittance advice.
pos 1300
Required
max —
PER
Payer WEB Sitevariant 3 of 3
- Required when any 2110 loop Healthcare Policy REF Segment is used. If not required by this implementation guide, do not send.
- This is a direct link to the policy location of the un-secure website.
pos 1300
Optional
max —
1000B LoopPayee Identification Looprequired
N1
Payee Identification
- Use this N1 loop to provide the name/address information of the payee. The identifying reference number is provided in N104.
pos 0800
Required
max —
N3
Payee Address
- 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.
pos 1000
Optional
max —
N4
Payee City, State, ZIP Code
- 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.
pos 1100
Optional
max —
REF
Payee Additional Identification
- 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.
pos 1200
Optional
max —
RDM
Remittance Delivery Method
- 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.
- Payer should coordinate this process with their Originating Depository Financial Institution (ODFI).
pos 1400
Optional
max —
DETAIL
2000 LoopHeader Number Loop
LX
Header Number
- Required when claim/service information is being provided in the transaction. If not required by this implementation guide, do not send.
- 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.
pos 0030
Required
max —
TS3
Provider Summary Information
- 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.
- 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.
pos 0050
Optional
max —
TS2
Provider Supplemental Summary Information
Required when the value of the Total DRG amount is not zero. If not required by this implementation guide, do not send.
- 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.
- Required for Medicare Part A. If not required by this implementation guide, do not send.
pos 0070
Optional
max —
2100 LoopClaim Payment Information Looprequired
CLP
Claim Payment Information
- For CLP segment occurrence limitations, see section 1.3.2, Other Usage Limitations.
pos 0100
Required
max —
CAS
Claim Adjustment
- 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).
- Required when dollar amounts and/or quantities are being adjusted at the claim level. If not required by this implementation guide, do not send.
pos 0200
Optional
max 99
NM1
Patient Namevariant 1 of 7
- 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.
pos 0300
Required
max —
NM1
Insured Namevariant 2 of 7
- In the case of Medicare and Medicaid, the insured patient is always the subscriber and this segment is not used.
- 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.
- 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).
pos 0300
Optional
max —
NM1
Corrected Patient/Insured Namevariant 3 of 7
- 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.
- Required when needed to provide corrected information about the patient or insured. If not required by this implementation guide, do not send.
pos 0300
Optional
max —
NM1
Service Provider Namevariant 4 of 7
- 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.
- Required when the rendering provider is different from the payee. If not required by this implementation guide, do not send.
pos 0300
Optional
max —
NM1
Crossover Carrier Namevariant 5 of 7
- 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.
- 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.
pos 0300
Optional
max —
NM1
Corrected Priority Payer Namevariant 6 of 7
- 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.
- 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.
pos 0300
Optional
max —
NM1
Other Subscriber Namevariant 7 of 7
- 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.
- 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.
pos 0300
Optional
max —
MIA
Inpatient Adjudication Information
- 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.
- 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.
pos 0330
Optional
max —
MOA
Outpatient Adjudication Information
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.
- 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.
- 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.
pos 0350
Optional
max —
REF
Other Claim Related Identificationvariant 1 of 2
- 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.
pos 0400
Optional
max 5
REF
Rendering Provider Identificationvariant 2 of 2
- The NM1 segment always contains the primary reference number.
- 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.
pos 0400
Optional
max 10
DTM
Statement From or To Datevariant 1 of 3
- 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.
- 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.
- 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.
pos 0500
Optional
max 2
DTM
Coverage Expiration Datevariant 2 of 3
- Required when payment is denied because of the expiration of coverage. If not required by this implementation guide, do not send.
pos 0500
Optional
max —
DTM
Claim Received Datevariant 3 of 3
- 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.
pos 0500
Optional
max —
PER
Claim Contact Information
- Required when there is a claim specific communications contact. If not required by this implementation guide, do not send.
- 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.
pos 0600
Optional
max 2
AMT
Claim Supplemental Information
- 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.
- 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.
pos 0620
Optional
max 13
QTY
Claim Supplemental Information Quantity
- Use this segment to convey information only. It is not part of the financial balancing of the 835.
- Send one QTY for each non-zero value. Do not report any zero values.
- Required when the value of a specific quantity identified by the QTY01 qualifier is non-zero. If not required by this implementation guide, do not send.
pos 0640
Optional
max 14
2110 LoopService Payment Information Looprepeats 999
SVC
Service Payment Information
- 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.
- 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.
pos 0700
Required
max —
DTM
Service Date
- 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.
- Required when claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
- For retail 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.
pos 0800
Optional
max 2
CAS
Service Adjustment
- 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.
- 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.
- 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).
pos 0900
Optional
max 99
REF
Service Identificationvariant 1 of 4
- 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.
pos 1000
Optional
max 8
REF
Line Item Control Numbervariant 2 of 4
- 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.
- 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.
pos 1000
Optional
max —
REF
Rendering Provider Informationvariant 3 of 4
- 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.
pos 1000
Optional
max 10
REF
HealthCare Policy Identificationvariant 4 of 4
- 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.
- 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.
pos 1000
Optional
max 5
AMT
Service Supplemental Amount
- This segment is used to convey information only. It is not part of the financial balancing of the 835.
- 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.
pos 1100
Optional
max 9
QTY
Service Supplemental Quantity
- Use this segment to convey information only. It is not part of the financial balancing of the 835.
- 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.
pos 1200
Optional
max 6
LQ
Health Care Remark Codes
- Use this segment to provide informational remarks only. This segment has no impact on the actual payment. Changes in claim payment amounts are provided in the CAS segments.
- Required when remark codes or NCPDP Reject/Payment codes are necessary for the provider to fully understand the adjudication message for a given service line. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
pos 1300
Optional
max 99
SUMMARY
PLB
Provider Adjustment
- These adjustments can either decrease the payment (a positive number) or increase the payment (a negative number). Zero dollar adjustments are not allowed. Some examples of PLB adjustments are a Periodic Interim Payment (loans and loan repayment) or a capitation payment. Multiple adjustments can be placed in one PLB segment, grouped by the provider identified in PLB01 and the period identified in PLB02. Although the PLB reference numbers are not standardized, refer to 1.10.2.9 (Interest and Prompt Payment Discounts), 1.10.2.10 (Capitation and Related Payments or Adjustments), 1.10.2.12 (Balance Forward Processing), 1.10.2.16 (Post Payment Recovery) and 1.10.2.17 (Claim Overpayment Recovery) for code suggestions and usage guidelines.
- The codes and notations under PLB03 and its components apply equally to PLB05, 07, 09, 11 and 13.
- Required when reporting adjustments to the actual payment that are NOT specific to a particular claim or service. If not required by this implementation guide, do not send.
pos 0100
Optional
max —
SE
Transaction Set Trailer
pos 0200
Optional
max —
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