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Stedi maintains this guide based on public documentation from CGS Medicare. Contact CGS Medicare for official EDI specifications. To report any errors in this guide, please contact us. X12 835 Health Care Claim Payment Advice (X221A1) X12 Release 5010 Revised November 17, 2023 Go to Stedi Network This X12 Transaction S... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_0 |
(I03) ISA-05 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-06 I06 Interchange Sender ID Min 15 Max 15 String (AN) Required Identification code published by the sender for... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_1 |
only valid value within this transaction set for ST01 is 835. 835 Health Care Claim Payment Advice ST-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage n... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_2 |
835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 12 125 When using this transaction set to initiate a payment, all or some of BPR06 through BPR16 may be required, depending on the conventi... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_3 |
(AN) Required A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification. TRN03 identifies an organization. Usage notes This must be a 1 followed by the payer's EIN (or TIN). TRN-04 127 Originating Company Supplemental Code... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_4 |
physical location, property or an individual PR Payer N1-02 93 Payer Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XV Centers for Medicare and Medicaid Services ... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_5 |
of communication number EM Electronic Mail FX Facsimile TE Telephone 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 26 125 PER-04 364 Payer Contact Communic... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_6 |
NPI. For individual providers as payees, use this qualifier to represent the Social Security Number. XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). This only applies in cases of post payment recovery. See section 1.10.2.16 (Post Payment R... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_7 |
Use with FTP communications. OL On-Line Use with secured hosted or other electronic delivery. RDM-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name RDM02 is used to contain the name of a third party processor if needed, who would be the first recipient of the remittance. Usage notes When BM is used, the remit... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_8 |
Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 40 125 Monetary amount TS318 is the total Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage no... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_9 |
1 Max 15 Decimal number (R) Optional 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 45 125 Numeric value of quantity TS216 is the average diagnosis-related ... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_10 |
additional information. CLP-06 1032 Claim Filing Indicator Code Identifier (ID) Required 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 48 125 Code identify... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_11 |
Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Rea... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_12 |
8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 55 125 NM1 0300 Detail Header Number Loop Claim Payment Information Loop NM1 Corrected Patient Insured Name To supply ... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_13 |
carrier associated with this claim. NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view ... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_14 |
Variants (all may be used) NM1 Corrected Patient Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber NM1 Other Subscriber Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Patient Identifier (NM1-09) is present, then the other is required ... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_15 |
0 0 00 0 0000 00000000000 00000 000000 000 000000 0 0000000000000 00000000000 0000 00000000000000 0 XX XX XXX XXXX 0000000000 Max use 1 Optional MIA-01 380 Covered Days or Visits Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity MIA01 is the covered days. Usage notes Implementers utilizing the MI... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_16 |
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. Example MOA 000 00000000000 XXXXX XXXXXX XXX XX XXXXX 000 0000000 00000000000000 Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_17 |
036 Expiration DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the expiration date of the patient's coverage. 1 29 25, 8:52 PM CGS Medicare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides htt... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_18 |
Code to qualify amount AU Coverage Amount Use this monetary amount to report the total covered charges. This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan. This excludes charges considered not covered (i.e. per day television or tel... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_19 |
in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional Thi... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_20 |
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 t... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_21 |
Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03 and CLP04. Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 aft... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_22 |
(X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 95 125 REF 1000 Detail Header Number Loop Claim Payment Information Loop Service Payment Information Loop REF Line Item Control Number To specify identifying information Usage ... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_23 |
Federal Medicare or Medicaid Payment Mandate - Category 3 ZN Federal Medicare or Medicaid Payment Mandate - Category 4 ZO Federal Medicare or Medicaid Payment Mandate - Category 5 QTY-02 380 Service Supplemental Quantity Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1 29 25, 8:52 PM CGS Medic... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_24 |
in excess of the amount requested by the health plan. The amount accepted by the health plan is reported using code 72 (Authorized Return) and offset by the amount with code WO (Overpayment Recovery). The excess returned by the provider is reported as a negative amount using code B2, returning the excess funds to the p... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_25 |
01H25JG91Y6872AS5ZZTC7NMQ4 105 125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier PLB-06 782 Provider Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount PLB06 is the adjustment amount. Usage notes This is the adjustment... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_26 |
Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 110 125 IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control ... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_27 |
B6 49 CLP 7722337 1 179 108 12 119932404007801 11 1 NM1 QC 1 DOE SAM MI SJD99999 NM1 82 1 BAN ERIN XX 1811901945 AMT AU 108 SVC AD D0120 46 25 DTM 472 20190324 CAS CO 45 21 AMT B6 25 SVC AD D0274 60 34 DTM 472 20190324 CAS CO 45 26 AMT B6 34 SVC AD D1110 73 49 DTM 472 20190324 CAS CO 45 24 AMT B6 49 CLP 7722337 1 129 8... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_28 |
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