Format of Acme Insurance Policy - Excel by uii20287

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									BIG THANKS TO ODS for providing this template
Oregon Companion Document for 835 Remittance Advice
The objectives of this document are:
         *To clarify what information is needed by ODS where the guide indicates that the choice is dependent on the Payor.
         *To point out preferred selections for data element where multiple alternatives exist.

This document does not:
         *Modify the definition, condition, or use of data element or segment in the standard Implementation Guide.
         *Add any additional data elements or segments to the standard Implementation Guide.
         *Utilize any code or data values which are not valid in the standard Implementation Guide.
         *Change the meaning or intent of the standard Implementation Guide.

This document is based on the version of the 835 Payment/Advance Implementation Guide version 004010X091. With the following exception, the
Addenda (NPRM) have only been referenced, but not made part of this guide.
         *N2 Segments supporting additional Last Name information have been removed.

Participants:

Diana Lindsley, First Pacific Corp                         Monte Gund, Providence Helath System Alex Harkins, CorePolicy
Erik Olsen, ITG                                            Katie Van Rooy, Providence Health SystemChris Baker, Core Policy
Harold Powers, First Pacific Corp                          Dean Hill, Payer Connection             Denise Armstrong, Regence
Joseph Archer, First Pacific Corp                          Jim Mollard, Center Logic               Pat Van Dyke, ODS
Sharon Brown, First Pacific Corp                           Del Texley, LIPA
Phil Werner, First Pacific Corp                            Debbie Sorenson, Multnomah DCHS
Julie Ebner, OHSU                                          Kraig Goodlund, Providence Healthplan
Tammy Forsgren, Legacy                                     Natasha Farvan, OHSU
Jennifer Franks, Providence Health System                  Chris Apgar, Providence Health plan




ODS Health Plans
835 Payment/Advance                                                                                                                     Version 1.0
Version 004010X091                                                          1                                                              062402
ISA - Interchange Control Header
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: None
Loop ID: None

Example: ISA*00*bbbbbbbbbb*00*bbbbbbbbbb*30*123456789bbbbbb*30*381791480bbbbbb*010801*1452*U*00402*0000000001*0*P*:~

                                                             ATTRIBUTES
SEGMENT        ELEMENT                       USE   Min/Max   Data Type Codes/Values   Comments
               Authorization Information
ISA01          Qualifier                     R       2/2        ID           00
ISA02          Authorization Information     R      10/10       AN                    No password requirements
               Security Information
ISA03          Qualifier                     R       2/2        ID           00
ISA04          Security Information          R      10/10       AN                    No password requirements
               Sender Interchange ID
ISA05          Qualifier                     R       2/2        ID           30       Federal TIN of Sender. It will match the 837 inbound.
ISA06          Interchange Sender ID         R      15/15       AN
               Interchange Receiver ID
ISA07          Qualifier                     R       2/2        ID           30       Federal TIN of Receiver
ISA08          Interchange receiver ID       R      15/15       AN
ISA09          Interchange Date              R       6/6        DT         YYMMDD
ISA10          Interchange Time              R       4/4        TM          HHMM
ISA11          Interchange Control and ID    R       1/1        ID            U
ISA12          Interchange Control Version   R       5/5        ID          00401
ISA13          Interchange Control Number    R       9/9        N0                    Must match the Trailer IEA02 value.
               Acknowledgement
ISA14          Requested                     R       1/1          ID         0
ISA15          Usage Indicator               R       1/1          ID        P, T
ISA16          Component element             R       1/1     not defined      :       Use a colon (:)




ODS Health Plans
835 Payment/Advance                                                                                                            Version 1.0
Version 004010X091                                               2                                                                062402
GS - Functional Group Header
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: None
Loop ID: None

Example: GS*HC*123456789*381791480*20010801*1452*000000001*X*004010~

                                                                 ATTRIBUTES
SEGMENT        ELEMENT                           USE   Min/Max   Data Type Codes/Values   Comments
GS01           Functional Identifier Code        R       2/2        ID          HP
GS02           Application Senders Code          R      2/15        AN                    Established at time of Trading Partner Setup
GS03           Application Receiver's Code       R      2/15        AN                    Payer
GS04           Date                              R       8/8        DT     CCYYMMDD
GS05           Time                              R       4/4        TM       HHMM
GS06           Group Control Number              R       1/9        N0                    Established by sender
GS07           Responsible Agency Code           R       1/1        ID          X
               Version/Release/Industry
GS08           Identifier Code                   R      1/12        AN      004010X091

ST -- Transaction Set Header
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: None

Example: ST*835*1234~

                                                                 ATTRIBUTES
SEGMENT        ELEMENT                           USE   Min/Max   Data Type Codes/Values   Comments
ST01           Transaction Set Identifier Code   R       3/3        ID         835        The only valid value within ST01 is 835.
ST02           Transaction Set Control           R       4/9        AN                    ST02=SE02. Assigned by the sender. This number
               Number                                                                     must be unique within a specific group and
                                                                                          interchange. It is important in problem resolution.




ODS Health Plans
835 Payment/Advance                                                                                                                    Version 1.0
Version 004010X091                                                  3                                                                     062402
BPR -- Financial Information
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: None

Example: BPR*C*150000*C*ACH*CTX*01*999999992*DA*123456*1512345678*1999999999*01*999988880*DA*98765*19960901~
Regence, Providence, Kaiser will get a paper check & the EFT but the electronic 835 will be implemented in 2004.
                                                                   ATTRIBUTES
SEGMENT         ELEMENT                         USE      Min/Max   Data Type Codes/Values      Comments
BPR01           Transaction Handling Code       R           1/2        ID
BPR02           Total Actual Provider Payment   R          1/18         R
                Amount
BPR03           Credit/Debit Flag Code          R          1/1         ID           C          Value 'D' is not advised
BPR04           Payment Method Code             R          3/3         ID
BPR05           Payment Format Code              S         1/10        ID       CCP ,CTX
BPR06           DFI ID Number Qualifier          S         2/2         ID       01' OR '04'    BPR06 through BPR09 refer to the originating
                                                                                               financial institution and the originator's account
                                                                                               (Payer). This element required when BPR04 is
                                                                                               ACH, BOP, or FWT.
BPR07           Sender DFI Identifier            S         3/12       AN                       This element required when BPR04 is ACH, BOP, or
                                                                                               FWT.
BPR08           Account Number Qualifier         S         1/3         ID           DA         This element required when BPR04 is ACH, BOP, or
                                                                                               FWT.
BPR09           Sender Bank Account Number       S         1/35       AN                       This element required when BPR04 is ACH, BOP, or
                                                                                               FWT.
BPR10           Payer Identifier                 S        10/10       AN                       Must be the Federal Tax ID Number preceded by a
                                                                                               '1''. This element required when BPR04 is ACH,
                                                                                               BOP, or FWT.
BPR11           Originating Company              S         9/9        AN                       This element not needed.
                Supplemental Code
BPR12           DFI ID Number Qualifier          S         2/2         ID       01' OR '04'
BPR13           Receiver or Provider Bank ID     S         3/12       AN
                Number
BPR14           Account Number Qualifier         S         1/3         ID       DA' OR 'SG'
BPR15           Receiver or Provider Account     S         1/35       AN
                Number
BPR16           Check Issue or Effective Date   R          8/8         DT
BPR17           Business Function Code                     1/3




ODS Health Plans
835 Payment/Advance                                                                                                                        Version 1.0
Version 004010X091                                                     4                                                                      062402
TRN -- Reassociation Trace Number
Usage: Required
Segment Max Use within Loop: >1
Loop Repeat: 1
Loop ID: None

Example: TRN*1*12345*1512345678*199999999~

                                                               ATTRIBUTES
SEGMENT        ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
TRN01          Trace Type Code                 R       1/1        ID          1
TRN02          Check or EFT Trace Number       R      1/30        AN                    Assigned by sender.
TRN03          Payer Identifier (originating   R      10/10       AN                    Must be the Federal Tax ID Number preceded by a
               company)                                                                 '1''.
TRN04          Originating Company              S     1/30        AN                    This element not needed.
               Supplemental Code

CUR -- Foreign Currency Information
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: None

Example: CUR*PR*CAN*1.2~

                                                               ATTRIBUTES
SEGMENT        ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
CUR01          Entity Identifier Code          R       2/3        ID          PR        Use only when payment is not being made in US
                                                                                        dollars.
CUR02          Currency Code                   R       3/3        ID
CUR03          Exchange Rate                    S     4/10        R




ODS Health Plans
835 Payment/Advance                                                                                                                Version 1.0
Version 004010X091                                                5                                                                   062402
REF -- Receiver Identification
Usage: Situational
Segment Max Use within Loop: >1
Loop Repeat: 1
Loop ID: None

Example: REF*EV*1235678~

                                                             ATTRIBUTES
SEGMENT        ELEMENT                       USE   Min/Max   Data Type Codes/Values   Comments
REF01          Reference Identification      R       2/3        ID          EV        Use this segment only when the receiver of the
               Qualifier                                                              transaction is other than the payee i.e.
                                                                                      clearinghouse.
REF02          Receiver Identification       R      1/30        AN

REF -- Version Identification
Usage: Situational
Segment Max Use within Loop: >1
Loop Repeat: 1
Loop ID: None

Example: REF*F2*FS3.21~

                                                             ATTRIBUTES
SEGMENT        ELEMENT                       USE   Min/Max   Data Type Codes/Values   Comments
REF01          Reference Identification      R       2/3        ID          F2        ODS internally assigned version number for 835
               Qualifier                                                              module. To distinguish the payers' software version
                                                                                      in case payees were paid on an older version, etc.

REF02          Version Identification Code   R      1/30        AN




ODS Health Plans
835 Payment/Advance                                                                                                                 Version 1.0
Version 004010X091                                              6                                                                      062402
DTM -- Production Date
Usage: Situational
Segment Max Use within Loop: >1
Loop Repeat: 1
Loop ID: None

Example: DTM*405*19960317~

                                                                                   ATTRIBUTES
SEGMENT            ELEMENT                               USE          Min/Max      Data Type Codes/Values            Comments
DTM01              Date Time Qualifier                    R              3/3           ID              405           The production date must be supplied when the
                                                                                                                     cutoff date of the adjudication system is different
                                                                                                                     from the date of the 835.
DTM02              Production Date                        R              8/8           DT          ccyymmdd


N1 -- Payer Identification
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 1000A

Example: N1*PR*INSURANCE COMPANY OF TIMBUCKTU*XV*88888888~

                                                                                   ATTRIBUTES
SEGMENT            ELEMENT                               USE          Min/Max      Data Type Codes/Values            Comments
N101               Entity Identifier Code                 R              2/3           ID              PR
N102               Payer Name                             S              1/60          AN                            ODS Health Plan for Medical, Oregon Dental
                                                                                                                     Service for Dental or other names paying
                                                                                                                     organization if administrative services only.

N103               Identification Code Qualifier          S              1/2           ID                            Required if the National PlanID is transmitted in
                                                                                                                     N104


N104               Identification Code                    S              2/80          AN                            Required if the National PlanID is mandated for use.



If a vendor wanted the payment to be sent to the vendor vs. the physician, how can that be communicated in the 837. Would it be in the pay to provider or the bill to
provider? ODS will pay whatever is in their system, whatever is in the contract.



ODS Health Plans
835 Payment/Advance                                                                                                                                                   Version 1.0
Version 004010X091                                                                     7                                                                                 062402
ODS Health Plans
835 Payment/Advance       Version 1.0
Version 004010X091    8      062402
N3 -- Payer Address
Usage: Required
Segment Max Use within Loop: >1
Loop Repeat: 1
Loop ID: 1000A

Example: N3*100 MAIN STREET~

                                                              ATTRIBUTES
SEGMENT        ELEMENT                        USE   Min/Max   Data Type Codes/Values   Comments
N301           Payer Address Line             R      1/55        AN
N302           Payer Address Line              S     1/55        AN

N4 -- Payer City, State, Zip Code
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 1000A

Example: N4*KANSAS CITY*MO*64108~

                                                              ATTRIBUTES
SEGMENT        ELEMENT                        USE   Min/Max   Data Type Codes/Values   Comments
N401           Payer City Name                R      2/30        AN
N402           Payer State or Province Code   R       2/2        ID
N403           Payer Zip Code                 R      3/15        ID




ODS Health Plans
835 Payment/Advance                                                                               Version 1.0
Version 004010X091                                               9                                   062402
REF -- Additional Payer Identification
Usage: Situational
Segment Max Use within Loop: >1
Loop Repeat: 4
Loop ID: 1000A

Example: REF*2U*98765~

                                                             ATTRIBUTES
SEGMENT        ELEMENT                       USE   Min/Max   Data Type Codes/Values   Comments
REF01          Reference Identification      R       2/3        ID                    Additional identifier is not needed.
               Qualifier
REF02          Additional Payer Identifier   R      1/30        AN

PER -- Payer Contact Information
Usage: Situational
Segment Max Use within Loop: >1
Loop Repeat: 1
Loop ID: 1000A

Example: PER*CX*JOHN WAYNE*TE*3035551212~

                                                             ATTRIBUTES
SEGMENT        ELEMENT                       USE   Min/Max   Data Type Codes/Values   Comments
PER01          Contact Function Code         R       2/2        ID          CX
PER02          Payer Contact Name             S     1/60        AN
PER03          Communication Number           S      2/2        ID       EM,FX,TE
               Qualifier
PER04          Payer Contact Communication    S     1/80        AN
               Number
PER05          Communication Number           S      2/2        ID      EM,EX,FX,TE
               Qualifier
PER06          Payer Contact Communication    S     1/80        AN
               Number
PER07          Communication Number           S      2/2        ID          EX
               Qualifier
PER08          Payer Contact Communication    S     1/80        AN
               Number




ODS Health Plans
835 Payment/Advance                                                                                                          Version 1.0
Version 004010X091                                             10                                                               062402
N1 -- Payee Identification
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 1000B

Example: N1*PE* CYBILS MENTAL HOSPITAL*XX*12345678~

                                                               ATTRIBUTES
SEGMENT        ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
N101           Entity Identifier Code          R       2/3        ID          PE
N102           Payee Name                       S     1/60        AN
N103           Identification Code Qualifier   R       1/2        ID          FI        TIN or SSN, if SSN is used as a TIN
N104           Identification Code             R      2/80        AN

N3 -- Payee Address
Usage: Situational
Segment Max Use within Loop: >1
Loop Repeat: 1
Loop ID: 1000B

Example: N3*Suite 200*1000 Main Street~

                                                               ATTRIBUTES
SEGMENT        ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
N301           Payee Address Line              R      1/55        AN                    Will send this segment only if needed to convey
                                                                                        information to a transaction receiver I.e.
                                                                                        clearinghouse.
N302           Payee Address Line               S     1/55        AN




ODS Health Plans
835 Payment/Advance                                                                                                                   Version 1.0
Version 004010X091                                               11                                                                      062402
N4 -- Payee City, Street, Zip Code
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 1000B

Example: N4*Beverly Hills*CA*90210~

                                                              ATTRIBUTES
SEGMENT        ELEMENT                        USE   Min/Max   Data Type Codes/Values   Comments
N401           Payee City Name                R      2/30        AN                    Will send this segment only if needed to convey
                                                                                       information to a transaction receiver I.e.
                                                                                       clearinghouse.
N402           Payee State or Province Code   R       2/2        ID
N403           Payee Zip Code                 R      3/15        ID
N404           Country Code                    S      2/3        ID

REF -- Payee Additional Identification
Usage: Situational
Segment Max Use within Loop: >1
Loop Repeat: >1
Loop ID: 1000B

Example: REF*PQ*12345678~

                                                              ATTRIBUTES
SEGMENT        ELEMENT                        USE   Min/Max   Data Type Codes/Values   Comments
REF01          Reference Identification       R       2/3        ID                    This segment is not needed.
               Qualifier
REF02          Additional Payee Identifier    R      1/30        AN




ODS Health Plans
835 Payment/Advance                                                                                                                  Version 1.0
Version 004010X091                                              12                                                                      062402
LX -- Header Number
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2100

Example: LX**961011~

                                                               ATTRIBUTES
SEGMENT        ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
LX01           Assigned Number                 R       1/6        N0

TS3 -- Provider Summary Information
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2000

Example: TS3*123456*11*19961031*10*130957.66~

                                                               ATTRIBUTES
SEGMENT        ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
TS301          Provider Identifier             R      1/30        AN                    Use TIN in Payer system
TS302          Facility Type Code              R       1/2        AN
TS303          Fiscal Period Date              R       8/8        DT                    Default to 12/31 of current year if unknown.
TS304          Total Claim Count               R      1/15        R
TS305          Total Claim Charge Amount       R      1/18        R
TS306          Total Covered Charge Amount      S     1/18        R                     For use by Medicare Part A only.

TS307          Total Noncovered Charge          S     1/18        R                     For use by Medicare Part A only.
               Amount
TS308          Total Denied Charge Amount       S     1/18        R                     For use by Medicare Part A only.
TS309          Total Provider Payment Amount    S     1/18        R                     For use by Medicare Part A only.

TS310          Total Interest Amount            S     1/18        R                     For use by Medicare Part A only.
TS311          Total Contractual Adjustment     S     1/18        R                     For use by Medicare Part A only.
               Amount




ODS Health Plans
835 Payment/Advance                                                                                                                    Version 1.0
Version 004010X091                                               13                                                                       062402
TS3 -- Provider Summary Information
(Continued)

TS312         Total Gramm-Rudman                S   1/18   R    For use by Medicare Part A only.
              Reduction Amount
TS313         Total MSP Payer Amount            S   1/18   R    For use by Medicare Part A only.
TS314         Total Blood Deductible Amount     S   1/18   R    For use by Medicare Part A only.

TS315         Total Non-Lab Charge Amount       S   1/18   R    For use by Medicare Part A only.

TS316         Total Coinsurance Amount          S   1/18   R    For use by Medicare Part A only.
TS317         Total HCPCS Reported Charge       S   1/18   R    For use by Medicare Part A only.
              Amount
TS318         Total HCPCS Payable Amount        S   1/18   R    For use by Medicare Part A only.

TS319         Total Deductible Amount           S   1/18   R    For use by Medicare Part A only.
TS320         Total Professional Component      S   1/18   R    For use by Medicare Part A only.
              Amount
TS321         Total MSP Patient Liability Met   S   1/18   R    For use by Medicare Part A only.
              Amount
TS322         Total Patient Reimbursement       S   1/18   R    For use by Medicare Part A only.
              Amount
TS323         Total PIP Claim Count             S   1/15   R    For use by Medicare Part A only.
TS324         Total PIP Adjustment Amount       S   1/18   R    For use by Medicare Part A only.




ODS Health Plans
835 Payment/Advance                                                                                Version 1.0
Version 004010X091                                         14                                         062402
TS2 -- Provider Supplemental Summary Information
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2000

Example: TS2*59786*55375.77~

                                                                  ATTRIBUTES
SEGMENT        ELEMENT                            USE   Min/Max   Data Type Codes/Values   Comments
TS201          Total DRG Amount                    S     1/18        R                     This segment is used by Medicare Part A only.
TS202          Total Federal Specific Amount       S     1/18        R

TS203          Total Hospital Specific Amount      S     1/18        R

TS204          Total Disproportionate Share        S     1/18        R
               Amount
TS205          Total Capital Amount                S     1/18        R
TS206          Total Indirect Medical Education    S     1/18        R
               Amount
TS207          Total Outlier Day Count             S     1/15        R
TS208          Total Day Outlier Amount            S     1/18        R
TS209          Total Cost Outlier Amount           S     1/18        R
TS210          Average DRG Length of Stay          S     1/15        R
TS211          Total Discharge Count               S     1/15        R
TS212          Total Cost Report Day Count         S     1/15        R
TS213          Total Covered Day Count             S     1/15        R
TS214          Total Noncovered Day Count          S     1/15        R
TS215          Total MSP Pass-Through              S     1/18        R
               Amount
TS216          Average DRG Weight                  S     1/15        R
TS217          Total PPS Capital FSP DRG           S     1/18        R
               Amount
TS218          Total PPS Capital HSP DRG           S     1/18        R
               Amount
TS219          Total PPS DSH DRG Amount            S     1/18        R




ODS Health Plans
835 Payment/Advance                                                                                                                        Version 1.0
Version 004010X091                                                  15                                                                        062402
CLP -- Claim Payment Information
Usage: Required
Segment Max Use within Loop: >1
Loop Repeat: >1
Loop ID: 2100

Example: CLP*7722337*1*211366.97*138018.4**12*119932404007801~

                                                               ATTRIBUTES
SEGMENT        ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
CLP01          Patient Control Number          R      1/38        AN                    Use value from CLP01 of ANSI ASC X12 837. If no
                                                                                        value, default to '0'.
CLP02          Claim Status Code               R       1/2        ID                    ODS will not support the Payor to Payor model at
                                                                                        this time. Valid Values will be: 1 = processed as
                                                                                        primary; 2 = processed as secondary; 3 = processed
                                                                                        as tertiary; 4 = denied; 22 = Reversal of Previous
                                                                                        Payment; 25 = Predetermination Pricing Only
                                                                                        (Dental specific)

CLP03          Total Claim Charge Amount       R      1/18        R
CLP04          Claim Payment Amount            R      1/18        R                     May be any value--positive, negative or zero.??
CLP05          Patient Responsibility Amount    S     1/18        R

CLP06          Claim Filing Indicator Code     R       1/2        ID                    Will mirror the value in SBR09 of the 837.
CLP07          Payer Claim Control Number       S     1/30        AN                    Payer Claim Number
CLP08          Facility Type Code               S      1/2        AN                    This number was received in CLM05-1 of the 837

CLP09          Claim Frequency Code             S      1/1        ID                    Applies to institutional claims only. CLM05-2
CLP11          Diagnosis Related Group          S      1/4        ID                    Institutional claims only. Required when adjudication
               (DRG) Code                                                               considers the DRG.
CLP12          DRG Weight                       S     1/15        R                     Institutional claims only. Required when adjudication
                                                                                        considers the DRG.
CLP13          Discharge Fraction               S     1/10        R                     Institutional claims only. Required when considered
                                                                                        in the adjudication process.




ODS Health Plans
835 Payment/Advance                                                                                                                     Version 1.0
Version 004010X091                                               16                                                                        062402
CAS -- Claim Adjustment
Usage: Situational
Segment Max Use within Loop: 99
Loop Repeat: 99
Loop ID: 2100

Example: CAS*PR*1*793~

                                                              ATTRIBUTES
SEGMENT        ELEMENT                        USE   Min/Max   Data Type Codes/Values   Comments
CAS01          Claim Adjustment Group Code    R       1/2        ID                    Claim level adjustments will include interest,
                                                                                       deferred compensation, prompt pay discounts.
CAS02          Claim Adjustment Reason Code   R       1/5        ID

CAS03          Adjustment Amount              R      1/18        R
CAS04          Adjustment Quantity             S     1/15        R                     Use when service units are adjusted from the
                                                                                       originally submitted amount.
CAS05          Claim Adjustment Reason Code    S      1/5        ID

CAS06          Adjustment Amount               S     1/18        R
CAS07          Adjustment Quantity             S     1/15        R                     Use when service units are adjusted from the
                                                                                       originally submitted amount.
CAS08          Claim Adjustment Reason Code    S      1/5        ID

CAS09          Adjustment Amount               S     1/18        R
CAS10          Adjustment Quantity             S     1/15        R                     Use when service units are adjusted from the
                                                                                       originally submitted amount.
CAS11          Claim Adjustment Reason Code    S      1/5        ID

CAS12          Adjustment Amount               S     1/18        R
CAS13          Adjustment Quantity             S     1/15        R                     Use when service units are adjusted from the
                                                                                       originally submitted amount.
CAS14          Claim Adjustment Reason Code    S      1/5        ID

CAS15          Adjustment Amount               S     1/18        R
CAS16          Adjustment Quantity             S     1/15        R                     Use when service units are adjusted from the
                                                                                       originally submitted amount.
CAS17          Claim Adjustment Reason Code    S      1/5        ID

CAS18          Adjustment Amount               S     1/18        R
CAS19          Adjustment Quantity             S     1/15        R                     Use when service units are adjusted from the
                                                                                       originally submitted amount.


ODS Health Plans
835 Payment/Advance                                                                                                                     Version 1.0
Version 004010X091                                              17                                                                         062402
NM1 -- Patient Name
Usage: Required
Segment Max Use within Loop: 9
Loop Repeat: 1
Loop ID: 2100

Example: NM1*QC*1*SHEPARD*SAM*O***HN*666666666A~

                                                               ATTRIBUTES
SEGMENT        ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
NM101          Entity Identifier Code          R       2/3        ID          QC
NM102          Entity Type Qualifier           R       1/1        ID          1
NM103          Patient Last Name               R      1/35        AN
NM104          Patient Name First              R      1/25        AN
NM105          Patient Name Middle              S     1/25        AN
NM107          Patient Name Suffix              S     1/10        AN
NM108          Identification Code Qualifier    S      1/2        ID          MI
NM109          Patient Identifier               S     2/80        AN                    The Member ID number .




ODS Health Plans
835 Payment/Advance                                                                                              Version 1.0
Version 004010X091                                               18                                                 062402
NM1 -- Insured Name
Usage: Situational
Segment Max Use within Loop: 9
Loop Repeat: 1
Loop ID: 2100

Example: NM1*IL*SHEPARD*JESSICA****HN*999887777A~

                                                               ATTRIBUTES
SEGMENT        ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
NM101          Entity Identifier Code          R       2/3        ID          IL
NM102          Entity Type Qualifier           R       1/1        ID          1,2
NM103          Subscriber Last Name             S     1/35        AN
NM104          Subscriber First Name            S     1/25        AN
NM105          Subscriber Middle Name           S     1/25        AN
NM107          Subscriber Suffix                S     1/10        AN
NM108          Identification Code Qualifier   R       1/2        ID          MI
NM109          Subscriber Identifier           R      2/80        AN                    The Member ID number .




ODS Health Plans
835 Payment/Advance                                                                                              Version 1.0
Version 004010X091                                               19                                                 062402
NM1 -- Corrected Patient/Insured Name
Usage: Situational
Segment Max Use within Loop: 9
Loop Repeat: 1
Loop ID: 2100

Example: NM1*74*1*SHEPARD*SAMUEL*O***C*666666666A~

                                                                ATTRIBUTES
SEGMENT        ELEMENT                          USE   Min/Max   Data Type Codes/Values   Comments
NM101          Entity Identifier Code           R       2/3        ID          74        ODS, Regence & Providence do not anticipate using
NM102          Entity Type Qualifier            R       1/1        ID         1 or 2     this segment.

NM103          Corrected Patient or Insured      S     1/35        AN
               Last Name
NM104          Corrected Patient or Insured      S     1/25        AN
               First Name
NM105          Corrected Patient or Insured      S     1/25        AN
               Middle Name
NM107          Corrected Patient or Insured      S     1/10        AN
               Suffix
NM108          Identification Code Qualifier     S      1/2        ID           C
NM109          Corrected Insured ID Indicator    S     2/80        AN




ODS Health Plans
835 Payment/Advance                                                                                                                 Version 1.0
Version 004010X091                                                20                                                                   062402
NM1 -- Service Provider Name
Usage: Situational
Segment Max Use within Loop: 9
Loop Repeat: 1
Loop ID: 2100

Example: NM1*82*2******XX*12345678~

                                                               ATTRIBUTES
SEGMENT        ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
NM101          Entity Identifier Code          R       2/3        ID          82        Rendering Provider Name will be included when
                                                                                        paying a clinic or similar group.
NM102          Entity Type Qualifier           R       1/1        ID         1 or 2
NM103          Rendering Provider Last or       S     1/35        AN
               Organization Name
NM104          Rendering Provider First Name    S     1/25        AN

NM105          Rendering Provider Middle        S     1/25        AN
               Name
NM107          Rendering Provider Suffix        S     1/10        AN
NM108          Identification Code Qualifier   R       1/2        ID
NM109          Rendering Provider Identifier   R      2/80        AN




ODS Health Plans
835 Payment/Advance                                                                                                                Version 1.0
Version 004010X091                                               21                                                                   062402
NM1 -- Crossover Carrier Name
Usage: Situational
Segment Max Use within Loop: 9
Loop Repeat: 1
Loop ID: 2100

Example: NM1*TT*2*ACME INSURANCE*****XV*123456789~

                                                               ATTRIBUTES
SEGMENT        ELEMENT                         USE   Min/Max   Data Type Codes/Values      Comments
NM101          Entity Identifier Code          R       2/3        ID           TT          Payers who participated in this meeting will support
                                                                                           outbound Payer to Payer crossover at a future date.
                                                                                           We will support only inbound payer-to-payer at this
                                                                                           time i.e. Medicare part B and A.

NM102          Entity Type Qualifier           R       1/1        ID           2
NM103          COB Carrier Name                R      1/35        AN
NM108          Identification Code Qualifier   R       1/2        ID     Multiple Values
                                                                             IG 115
NM109          COB Carrier Identifier          R      2/80        AN

NM1 -- Corrected Priority Payer Name
Usage: Situational
Segment Max Use within Loop: 9
Loop Repeat: 2
Loop ID: 2100

Example: NM1*PR*2*ACME INSURANCE*****XV*123456789~

                                                               ATTRIBUTES
SEGMENT        ELEMENT                         USE   Min/Max   Data Type Codes/Values      Comments
NM101          Entity Identifier Code          R       2/3        ID          PR
NM102          Entity Type Qualifier           R       1/1        ID           2
NM103          Corrected Priority Payer Name   R      1/35        AN

NM108          Identification Code Qualifier   R       1/2        ID
NM109          Corrected Priority Payer ID     R      2/80        AN
               Number




ODS Health Plans
835 Payment/Advance                                                                                                                      Version 1.0
Version 004010X091                                               22                                                                         062402
MIA -- Inpatient Adjudication Information
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2010

Example: MIA*0***138018.4~

                                                                 ATTRIBUTES
SEGMENT        ELEMENT                           USE   Min/Max   Data Type Codes/Values   Comments
MIA01          Covered Days or Visits Count      R      1/15        R                     This segment will be generated by Medicare
                                                                                          intermediaries.
MIA02          PPS Operating Outlier Amount       S     1/15        R

MIA03          Lifetime Psychiatric Days Count    S     1/15        R

MIA04          Claim DRG Amount                   S     1/18        R
MIA05          Remark Code                        S     1/30        AN
MIA06          Claim Disproportionate Share       S     1/18        R
               Amount
MIA07          Claim MSP Pass-through             S     1/18        R
               Amount
MIA08          Claim PPS Capital Amount           S     1/18        R
MIA09          PPS-Capital FSP DRG Amount         S     1/18        R

MIA10          PPS-Capital HSP DRG Amount         S     1/18        R

MIA11          PPS-Capital DSH DRG Amount         S     1/18        R

MIA12          Old Capital Amount                 S     1/18        R
MIA13          PPS-Capital IME Amount             S     1/18        R
MIA14          PPS-Operating Hospital             S     1/18        R
               Specific DRG Amount
MIA15          Cost Report Day count              S     1/15        R
MIA16          PPS-Operating Federal Specific     S     1/18        R
               DRG Amount
MIA17          Claims PPS Capital Outlier         S     1/18        R
               Amount




ODS Health Plans
835 Payment/Advance                                                                                                                    Version 1.0
Version 004010X091                                                 23                                                                     062402
MIA -- Inpatient Adjudication Information
(Continued)

MIA18          Claim Indirect Teaching Amount    S     1/18        R

MIA19          Nonpayable Professional           S     1/18        R
               Component Amount
MIA20          Remark Code                       S     1/30        AN
MIA21          Remark Code                       S     1/30        AN
MIA22          Remark Code                       S     1/30        AN
MIA23          Remark Code                       S     1/30        AN
MIA24          PPS-Capital Exception Amount      S     1/18        R


MOA -- Outpatient Adjudication Information
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2100

Example: MOA***MA01~

                                                                ATTRIBUTES
SEGMENT        ELEMENT                          USE   Min/Max   Data Type Codes/Values   Comments
MOA01          Reimbursement Rate                S     1/10        R                     This segment will be generated by Medicare
                                                                                         intermediaries.
MOA02          Claim HCPCS Payable Amount        S     1/18        R
MOA03          Remark Code                       S     1/30        AN
MOA04          Remark Code                       S     1/30        AN
MOA05          Remark Code                       S     1/30        AN
MOA06          Remark Code                       S     1/30        AN
MOA07          Remark Code                       S     1/30        AN
MOA08          Claim ESRD Payment Amount         S     1/18        R
MOA09          Nonpayable Professional           S     1/18        R
               Component Amount




ODS Health Plans
835 Payment/Advance                                                                                                                   Version 1.0
Version 004010X091                                                24                                                                     062402
REF -- Other Claim Related Identification
Usage: Situational
Segment Max Use within Loop: 99
Loop Repeat: 5
Loop ID: 2100

Example: REF*EA*666123~

                                                                ATTRIBUTES
SEGMENT        ELEMENT                          USE   Min/Max   Data Type Codes/Values   Comments
REF01          Reference Identification         R       2/3        ID                    Include information from CLP segment if present.
               Qualifier
REF02          Other Claim Related Identifier   R      1/30        AN

REF -- Rendering Provider Identification
Usage: Situational
Segment Max Use within Loop: 99
Loop Repeat: 10
Loop ID: 2100

Example: REF*1C*12345678~

                                                                ATTRIBUTES
SEGMENT        ELEMENT                          USE   Min/Max   Data Type Codes/Values   Comments
REF01          Reference Identification         R       2/3        ID                    Utilize value '1D' for OMAP healthcare providers
               Qualifier
REF02          Rendering Provider Secondary     R      1/30        AN                    Payers: Is it possible to track this back to the same
               Identifier                                                                REF segment from the 837?




ODS Health Plans
835 Payment/Advance                                                                                                                      Version 1.0
Version 004010X091                                                25                                                                        062402
DTM -- Claim Date
Usage: Situational
Segment Max Use within Loop: 9
Loop Repeat: 4
Loop ID: 2100

Example: DTM*233*19960916~

                                                             ATTRIBUTES
SEGMENT        ELEMENT                       USE   Min/Max   Data Type Codes/Values   Comments
DTM01          Date Time Qualifier           R       3/3        ID                    Service line level dates are preferred.
DTM02          Claim Date                    R       8/8        DT                    Are providers expecting payers to give them the
                                                                                      detail level on the 835? Payers prefer to do this at
                                                                                      the claim level.

PER -- Claim Contact Information
Usage: Situational
Segment Max Use within Loop: 3
Loop Repeat: 3
Loop ID: 2100

Example: PER*CX**TE*8005551212~

                                                             ATTRIBUTES
SEGMENT        ELEMENT                       USE   Min/Max   Data Type Codes/Values   Comments
PER01          Contact Function Code         R       2/2        ID          CX
PER02          Claim Contact Name             S     1/60        AN
PER03          Communication Number          R       2/2        ID
               Qualifier
PER04          Claim Contact Communication    S     1/80        AN
               Number
PER05          Communication Number           S      2/2        ID
               Qualifier
PER06          Claim Contact Communication    S     1/80        AN
               Number
PER07          Communication Number           S      2/2        ID
               Qualifier
PER08          Claim Contact Communication    S     1/80        AN
               Number




ODS Health Plans
835 Payment/Advance                                                                                                                   Version 1.0
Version 004010X091                                             26                                                                        062402
AMT -- Claim Supplemental Information
Usage: Situational
Segment Max Use within Loop: 20
Loop Repeat: 14
Loop ID: 2100

Example: AMT*T*49~

                                                                ATTRIBUTES
SEGMENT        ELEMENT                          USE   Min/Max   Data Type Codes/Values   Comments
AMT01          Amount Qualifier Code            R       1/3        ID                    Informational only. Will not use at this time.
ATM02          Claim Supplemental Information   R      1/18        R
               Amount

QTY -- Claim Supplemental Information Quantity
Usage: Situational
Segment Max Use within Loop: 20
Loop Repeat: 15
Loop ID: 2100

Example: QTY*ZK*3~

                                                                ATTRIBUTES
SEGMENT        ELEMENT                          USE   Min/Max   Data Type Codes/Values   Comments
QTY01          Quantity Qualifier               R       2/2        ID                    Informational only. Will not use at this time.
QTY02          Claim Supplemental Information   R      1/15        R
               Quantity




ODS Health Plans
835 Payment/Advance                                                                                                                       Version 1.0
Version 004010X091                                                27                                                                         062402
SVC -- Service Payment Information
Usage: Situational
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID: 2110

Example: SVC*HC:99214*100*80~

                                                              ATTRIBUTES
SEGMENT        ELEMENT                        USE   Min/Max   Data Type Codes/Values   Comments
SVC01          Composite Medical Procedure    R                                        Use the adjudicated Procedure code.

SVC01-1        Product/Service ID Qualifier   R       2/2        ID
SVC01-2        Procedure Code                 R      1/48        AN
SVC01-3        Procedure Modifier              S      2/2        AN
SVC01-4        Procedure Modifier              S      2/2        AN
SVC01-5        Procedure Modifier              S      2/2        AN
SVC01-6        Procedure Modifier              S      2/2        AN
SVC01-7        Procedure Code Description      S     1/80        AN
SVC02          Line Item Charge Amount        R      1/18        R
SVC03          Line Item Provider Payment     R      1/18        R
               Amount
SVC04          NUBC Revenue Code               S     1/48        AN




ODS Health Plans
835 Payment/Advance                                                                                                          Version 1.0
Version 004010X091                                              28                                                              062402
SVC -- Service Payment Information
(Continued)


SVC05          Units of Service Paid Count        S     1/15        R
SVC06          Composite Medical Procedure        S                 O                     Use when the adjudicated Procedure code is not the
                                                                                          same as the originally billed code.
SVC06-1        Product/Service ID Qualifier      R       2/2        ID
SVC06-2        Procedure Code                    R      1/48        AN
SVC06-3        Procedure Modifier                 S      2/2        AN
SVC06-4        Procedure Modifier                 S      2/2        AN
SVC06-5        Procedure Modifier                 S      2/2        AN
SVC06-6        Procedure Modifier                 S      2/2        AN
SVC06-7        Procedure Code Description         S     1/80        AN
SVC07          Original Units of Service Count    S     1/15         R                    Required when the paid units of service is different
                                                                                          from the submitted units of service in the original
                                                                                          claim.

DTM -- Service Date
Usage: Situational
Segment Max Use within Loop: 9
Loop Repeat: 3
Loop ID: 2110

Example: DTM*472*19961031~

                                                                 ATTRIBUTES
SEGMENT        ELEMENT                           USE   Min/Max   Data Type Codes/Values   Comments
DTM01          Date Time Qualifier               R       3/3        ID         472          Not likely that we'll see multiple dates. ODS has
                                                                                                    posed this to the X12 committee.
DTM02          Service Date                      R       8/8        DT      CCYYMMDD




ODS Health Plans
835 Payment/Advance                                                                                                                      Version 1.0
Version 004010X091                                                 29                                                                       062402
CAS -- Service Adjustment
Usage: Situational
Segment Max Use within Loop: 99
Loop Repeat: 99
Loop ID: 2110

Example: CAS*CO*A2*20~

                                                              ATTRIBUTES
SEGMENT        ELEMENT                        USE   Min/Max   Data Type Codes/Values   Comments
CAS01          Claim Adjustment Group Code    R       1/2        ID

CAS02          Claim Adjustment Reason Code   R       1/5        ID

CAS03          Adjustment Amount              R      1/18        R
CAS04          Adjustment Quantity             S     1/15        R
CAS05          Claim Adjustment Reason Code    S      1/5        ID

CAS06          Adjustment Amount               S     1/18        R
CAS07          Adjustment Quantity             S     1/15        R
CAS08          Claim Adjustment Reason Code    S      1/5        ID

CAS09          Adjustment Amount               S     1/18        R
CAS10          Adjustment Quantity             S     1/15        R
CAS11          Claim Adjustment Reason Code    S      1/5        ID

CAS12          Adjustment Amount               S     1/18        R
CAS13          Adjustment Quantity             S     1/15        R
CAS14          Claim Adjustment Reason Code    S      1/5        ID

CAS15          Adjustment Amount               S     1/18        R
CAS16          Adjustment Quantity             S     1/15        R
CAS17          Claim Adjustment Reason Code    S      1/5        ID

CAS18          Adjustment Amount               S     1/18        R
CAS19          Adjustment Quantity             S     1/15        R




ODS Health Plans
835 Payment/Advance                                                                               Version 1.0
Version 004010X091                                              30                                   062402
REF -- Service Identification

Usage: Situational
Segment Max Use within Loop: 99
Loop Repeat: 7
Loop ID: 2110

Example: REF*RB*100~

                                                          ATTRIBUTES
SEGMENT        ELEMENT                    USE   Min/Max   Data Type Codes/Values   Comments
REF01          Reference Identification   R       2/3        ID
               Qualifier
REF02          Provider Identifier        R      1/30        AN

REF -- Rendering Provider Information
Usage: Situational
Segment Max Use within Loop: 99
Loop Repeat: 10
Loop ID: 2110

Example: REF*HPI*12345678~

                                                          ATTRIBUTES
SEGMENT        ELEMENT                    USE   Min/Max   Data Type Codes/Values   Comments
REF01          Reference Identification   R       2/3        ID                    This segment will not be used at the line item level.
               Qualifier
REF02          Rendering Provider ID      R      1/30        AN




ODS Health Plans
835 Payment/Advance                                                                                                                Version 1.0
Version 004010X091                                          31                                                                        062402
AMT -- Service Supplemental Amount
Usage: Situational
Segment Max Use within Loop: 20
Loop Repeat: 12
Loop ID: 2110

Example: AMT*B6*425~

                                                               ATTRIBUTES
SEGMENT        ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
AMT01          Amount Qualifier Code           R       1/3        ID                    Informational only. Will not use at this time.
ATM02          Service Supplemental Amount     R      1/18        R

QTY -- Service Supplemental Quantity
Usage: Situational
Segment Max Use within Loop: 20
Loop Repeat: 6
Loop ID: 2110

Example: QTY*ZL*3.75~

                                                               ATTRIBUTES
SEGMENT        ELEMENT                         USE   Min/Max   Data Type Codes/Values   Comments
QTY01          Quantity Qualifier              R       2/2        ID                    Informational only. Will not use at this time.
QTY02          Service Supplemental Quantity   R      1/15        R
               Amount




ODS Health Plans
835 Payment/Advance                                                                                                                      Version 1.0
Version 004010X091                                               32                                                                         062402
LQ -- Health Care Remark Codes
Usage: Situational
Segment Max Use within Loop: 99
Loop Repeat: 99
Loop ID: 2110

Example: LQ*HE*12345~

                                                                ATTRIBUTES
SEGMENT        ELEMENT                          USE   Min/Max   Data Type Codes/Values   Comments
LQ01           Code List Qualifier Code         R       1/3        ID                    ODS & Regence not using this segment at this time.

LQ02           Remark Code                      R      1/30        AN

PLB -- Provider Adjustment
Usage: Situational
Segment Max Use within Loop: >1
Loop Repeat: >1
Loop ID: None

Example: PLB*123456*19960930*CV:9876514*1.27~

                                                                ATTRIBUTES
SEGMENT        ELEMENT                          USE   Min/Max   Data Type Codes/Values   Comments
PLB01          Provider Identifier              R      1/30        AN                    Not specific to a particular claim or service to the
                                                                                         amount of the actual payment. (Capitation and
                                                                                         related payments or adjustments) Refer to CAS
                                                                                         segment in loop 2100.
PLB02          Fiscal Period Date               R       8/8        DT
PLB03          Adjustment Identifier            R
PLB03-1        Adjustment Reason Code           R       2/2        ID
PLB03-2        Provider Adjustment Identifier    S     1/30        AN

PLB04          Provider Adjustment Amt          R      1/18        R
PLB05          Adjustment Identifier             S
PLB05-1        Adjustment Reason Code           R       2/2        ID
PLB05-2        Provider Adjustment Identifier    S     1/30        AN

PLB06          Provider Adjustment Amt          R      1/18        R



ODS Health Plans
835 Payment/Advance                                                                                                                        Version 1.0
Version 004010X091                                                33                                                                          062402
PLB07         Adjustment Identifier   S




ODS Health Plans
835 Payment/Advance                            Version 1.0
Version 004010X091                        34      062402
PLB -- Provider Adjustment
(Continued)


PLB07-1       Adjustment Reason Code           R   2/2    ID
PLB07-2       Provider Adjustment Identifier   S   1/30   AN

PLB08         Provider Adjustment Amt          S   1/18   R
PLB09         Provider Adjustment Identifier   S

PLB09-1       Adjustment Reason Code           R   2/2    ID
PLB09-2       Provider Adjustment Identifier   S   1/30   AN

PLB10         Provider Adjustment Amt          S   1/18   R
PLB11         Adjustment Identifier            S
PLB11-1       Adjustment Reason Code           R    2/2   ID
PLB11-2       Provider Adjustment Identifier   S   1/30   AN

PLB12         Provider Adjustment Amt          S   1/18   R
PLB13         Adjustment Identifier            S
PLB13-1       Adjustment Reason Code           R   2/2    ID
PLB13-2       Provider Adjustment Identifier   S   1/30   AN

PLB14         Provider Adjustment Amt          S   1/18   R




ODS Health Plans
835 Payment/Advance                                            Version 1.0
Version 004010X091                                        35      062402
SE - Transaction Set Trailer
Usage: Required
Segment Max Use within Loop: 1
Loop Repeat: 1
Loop ID:

Example: SE*45*1234~

                                                             ATTRIBUTES
SEGMENT        ELEMENT                       USE   Min/Max   Data Type Codes/Values   Comments
SE01           Transaction Segment Control   R      1/10        N0                    Assigned by sender
SE02           Transaction Set Control       R       4/9        AN                    ST02=SE02
               Number

GE - Functional Group Trailer
Usage: Required
Segment Max Use within Loop:
Loop Repeat: 1
Loop ID:

Example: GE*1*1~

                                                             ATTRIBUTES
SEGMENT        ELEMENT                       USE   Min/Max   Data Type Codes/Values   Comments
GE01           Number of Transaction          R      1/6        N0
               Transaction Set Control
GE02           Number                         R      1/9        N0




ODS Health Plans
835 Payment/Advance                                                                                        Version 1.0
Version 004010X091                                             36                                             062402
IEA - Interchange Control Trailer
Usage: Required
Segment Max Use within Loop:
Loop Repeat: 1
Loop ID:

Example: IEA*1*000000001~

                                                            ATTRIBUTES
SEGMENT        ELEMENT                      USE   Min/Max   Data Type Codes/Values   Comments
IEA01          Number of Included            R      1/5        N0
IEA02          Interchange Control Number    R      9/9        N0




ODS Health Plans
835 Payment/Advance                                                                             Version 1.0
Version 004010X091                                            37                                   062402

								
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