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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 |
FAC DTM 405 20190827 N1 PR ANY PLAN USA N3 1 WALK THIS WAY N4 ANYCITY OH 45209 PER CX TE 8661112222 PER BL EDI TE 8002223333 EM EDI.SUPPORT ANYPAYER.COM PER IC UR WWW.ANYPAYER.COM N1 PE PROVIDER XX 1123454567 N3 2255 ANY ROAD N4 ANY CITY CA 12211 REF TJ 123456789 LX 1 CLP PCN 1 25 12 10 12 CLAIMNUMB 11 1 NM1 QC 1 LAST ... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_29 |
https: www.stedi.com app guides view cgs-medicare health-care-claim-paymentadvice-x221a1 01H25JG91Y6872AS5ZZTC7NMQ4 124 125 Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including X12, which is a trademark of X... | /kaggle/input/edi-db/CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c28f9651cbfa9304ff4372b535411616 | c28f9651cbfa9304ff4372b535411616_30 |
GAINWELL TECHNOLOGIES Louisiana Medicaid 837 Health Care Claim-Institutional Companion Guide Based on ASC X12N Version 005010X223A2 CORE v5010 Master Companion Guide Template Issued January 2018 Version 1.6 Revised 1 14 2025 837 Institutional Companion Guide i Revision History See Appendix C. Usage Information Document... | /kaggle/input/edi-db/837_Institutional_Companion_Guide.pdf | 0d6c8734dc38c90bb4671e7915172318 | 0d6c8734dc38c90bb4671e7915172318_0 |
Implementation Guide instructions. This section describes how the table, for the Louisiana Medicaid specific 837I transaction, is organized by columns and their descriptions. Section 10, Table 2 837I Health Care Claim, should be used as a reference for 837I transactions submitted to Louisiana Medicaid. Table 2 contains... | /kaggle/input/edi-db/837_Institutional_Companion_Guide.pdf | 0d6c8734dc38c90bb4671e7915172318 | 0d6c8734dc38c90bb4671e7915172318_1 |
provider notice section of www.lamedicaid.com. 4.3 Re-Transmission Procedure Providers submitters should contact the Gainwell EDI Department via email at HipaaEDI Gainwelltechnologies.com if an 837I claim file is processed late or missing. If a file is rejected, the errors must be corrected and then the file can be res... | /kaggle/input/edi-db/837_Institutional_Companion_Guide.pdf | 0d6c8734dc38c90bb4671e7915172318 | 0d6c8734dc38c90bb4671e7915172318_2 |
Service line data is required when reporting inpatient, outpatient and home health claims or when payment adjustments (reduction to billed charges or denial) are related to specific claim lines. Since Louisiana Medicaid is a claim line processor, all adjustments are line specific, except for inpatient institutional cla... | /kaggle/input/edi-db/837_Institutional_Companion_Guide.pdf | 0d6c8734dc38c90bb4671e7915172318 | 0d6c8734dc38c90bb4671e7915172318_3 |
segment that Louisiana Medicaid has something additional, over and above, the information in the Technical Report Type 3 (TR3). That information can: Limit the repeat of loops, or segments. Limit the length of a simple data element. Specify a sub-set of the Implementation Guides internal code listings. Clarify the use ... | /kaggle/input/edi-db/837_Institutional_Companion_Guide.pdf | 0d6c8734dc38c90bb4671e7915172318 | 0d6c8734dc38c90bb4671e7915172318_4 |
Guide 20 TR3 Page Loop ID Reference Name Codes Length Notes Comments Element Separator 1 NM108 Identification Code Qualifier Member ID Qualifier 1 2 Value is MI Member Identification Element Separator 1 NM109 Identification Code 13 digit Louisiana Medicaid Recipient ID Number 2 80 Value is the thirteen digit Medicaid R... | /kaggle/input/edi-db/837_Institutional_Companion_Guide.pdf | 0d6c8734dc38c90bb4671e7915172318 | 0d6c8734dc38c90bb4671e7915172318_5 |
coexist or develop during the patient s treatment. You may enter up to 12 additional diagnosis codes. Element Separator 1 HI01-01 Code List Qualifier Code Qualifier Code 1 3 Code BF Use for service discharge dates before 10 01 2015 Code ABF Use for service discharge dates on or after 10 01 2015 837 Institutional Compan... | /kaggle/input/edi-db/837_Institutional_Companion_Guide.pdf | 0d6c8734dc38c90bb4671e7915172318 | 0d6c8734dc38c90bb4671e7915172318_6 |
has previously processed the claim. Element Separator 1 356 SBR09 Insurance Type Code 11,12,13,14,15,16, 17,AL,BL,CH,CI, DS,FI,HM,LM,TV, VA,ZZ 1 2 Do NOT use MC for this segment when reporting information about another payer or payers involved in this claim. Use MA when billing Medicare Advantage claims, Use one of the... | /kaggle/input/edi-db/837_Institutional_Companion_Guide.pdf | 0d6c8734dc38c90bb4671e7915172318 | 0d6c8734dc38c90bb4671e7915172318_7 |
Loop ID-2310B Rendering Provider. Element Separator 1 REF01 Reference Identification Qualifier G2 2 3 Value is G2 Louisiana Medicaid 7- digit Provider Number. Element Separator 1 REF02 Reference Identification Louisiana Medicaid Provider Number 1 7 If the Rendering Provider is an atypical provider who has not registere... | /kaggle/input/edi-db/837_Institutional_Companion_Guide.pdf | 0d6c8734dc38c90bb4671e7915172318 | 0d6c8734dc38c90bb4671e7915172318_8 |
submitting claim files to Production environment. Appendix B Business Scenarios and Claim Encounter Example This section describes a few special billing scenarios and transaction examples follow. The first scenario describes the electronic billing to Medicaid for medical services of dual-eligible recipients (i.e., elig... | /kaggle/input/edi-db/837_Institutional_Companion_Guide.pdf | 0d6c8734dc38c90bb4671e7915172318 | 0d6c8734dc38c90bb4671e7915172318_9 |
EAF 406 837 Institutional Companion Guide 44 LX 3 SV1 0450 HC:99283:25 434 UN 1 DTP 472 D8 20140114 SVD MOL001 0 HC:99283:25 0450 1 CAS PR 51 434 (These are non-covered services because this is a pre-existing condition) DTP 573 D8 20150301 AMT EAF 434 - --------continue transaction b. Scenario 2 - CLAIMS FOR RECIPIENTS... | /kaggle/input/edi-db/837_Institutional_Companion_Guide.pdf | 0d6c8734dc38c90bb4671e7915172318 | 0d6c8734dc38c90bb4671e7915172318_10 |
999999999 REF EI 999999999 LOOP 2300 In Loop ID-2300 data element CLM01, enter the Gainwell assigned CLM 4275127042400 500 11:A:7 Y A ICN number rather than the Provider's Patient Control Number. Y In element CLM05-3 use Claim Frequency Type Code 7: Debit or Replacement adjustment. LOOP 2320 In Loop ID-2320 include all... | /kaggle/input/edi-db/837_Institutional_Companion_Guide.pdf | 0d6c8734dc38c90bb4671e7915172318 | 0d6c8734dc38c90bb4671e7915172318_11 |
HIPAA Transaction Standard Companion Guide Healthcare Claim Payment Advice ASC X12N 835 Version 005010X221A1 for State of Idaho MMIS Date of Publication: 02 29 2024 Document Number: TL419 Version: 11.0 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page ii Revision History Vers... | /kaggle/input/edi-db/CAQH 5010 835 Companion Guide (1).pdf | 69f62a9d267e4454bc0b0364e4df734f | 69f62a9d267e4454bc0b0364e4df734f_0 |
15 This row type exists to limit the length of the specified data element. 196 2100C REF Subscriber Additional 197 2100C REF01 Reference Identification Qualifier 18, 49, 6P, These are the only codes transmitted by Gainwell MS Healthcare. Plan Network Identification Number N6 This row type exists when a note for a parti... | /kaggle/input/edi-db/CAQH 5010 835 Companion Guide (1).pdf | 69f62a9d267e4454bc0b0364e4df734f | 69f62a9d267e4454bc0b0364e4df734f_1 |
Flows Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 4 of 22 4.1. Process Flows Below is the TPA Portal Services Process Flow (Retrieval of an 835 using the TPA Portal Services). Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page ... | /kaggle/input/edi-db/CAQH 5010 835 Companion Guide (1).pdf | 69f62a9d267e4454bc0b0364e4df734f | 69f62a9d267e4454bc0b0364e4df734f_2 |
(paid, denied, reversed, etc.). Once generated, the 835 file(s) can be downloaded via the trading partner s site. The following acknowledgments reports related to the submission of EDI transactions by a trading partner are not sent out for 835 transactions. 8.1. Report Inventory (Not Sent for 835 Transactions) TA1 Inte... | /kaggle/input/edi-db/CAQH 5010 835 Companion Guide (1).pdf | 69f62a9d267e4454bc0b0364e4df734f | 69f62a9d267e4454bc0b0364e4df734f_3 |
Element Separator 1 BPR16 Date CCYYMMDD 8 EFT or Check Issue Date Segment End 1 77 HEAD ER TRN Reassociation Trace Number TRN 3 Element Separator 1 TRN01 Trace Type Code 1 Current Transaction Trace Number 1 2 Element Separator 1 TRN02 Reference Identification 1 50 Check or EFT Trace Number Element Separator 1 TRN03 Ori... | /kaggle/input/edi-db/CAQH 5010 835 Companion Guide (1).pdf | 69f62a9d267e4454bc0b0364e4df734f | 69f62a9d267e4454bc0b0364e4df734f_4 |
Separator 1 CAS11 Claim Adjustment Reason Code 1 5 Fourth claim adjustment reason code Element Separator 1 CAS12 Monetary Amount 1 18 Fourth claim adjustment amount Element Separator 1 Element Separator 1 135 CAS14 Claim Adjustment Reason Code 1 5 Fifth claim adjustment reason code Element Separator 1 CAS15 Monetary Am... | /kaggle/input/edi-db/CAQH 5010 835 Companion Guide (1).pdf | 69f62a9d267e4454bc0b0364e4df734f | 69f62a9d267e4454bc0b0364e4df734f_5 |
Reason Code 1 5 First claim adjustment reason code Element Separator 1 199 CAS03 Monetary Amount 1 18 First claim adjustment amount Element Separator 1 Element Separator 1 CAS05 Claim Adjustment Reason Code 1 5 Second claim adjustment reason code Element Separator 1 CAS06 Monetary Amount 1 18 Second claim adjustment am... | /kaggle/input/edi-db/CAQH 5010 835 Companion Guide (1).pdf | 69f62a9d267e4454bc0b0364e4df734f | 69f62a9d267e4454bc0b0364e4df734f_6 |
Separator 1 IEA01 Number of Included Functional Groups 1 1 5 Element Separator 1 IEA02 Interchange Control Number 9 Assigned by Sender - Pad Left with Zeros Must be identical to value ISA13 Segment Terminator 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 22 of 22 Append... | /kaggle/input/edi-db/CAQH 5010 835 Companion Guide (1).pdf | 69f62a9d267e4454bc0b0364e4df734f | 69f62a9d267e4454bc0b0364e4df734f_7 |
31 CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Administrators, LLC. vii List of Figures Figure 1. GPNet V5010 Test 837 Claims Transaction Flow..................................................................................... 7 Figure 2. GPNet V5010 837 Claims Transaction Flow...................... | /kaggle/input/edi-db/837I_compguide.pdf | 815189f6dea52a5dd9b38b3bba0f5280 | 815189f6dea52a5dd9b38b3bba0f5280_0 |
001.asp) has been established in order to broadcast urgent messages. 2.2 Trading Partner Registration An EDI Trading Partner is any entity (provider, billing service, clearinghouse, software vendor, employer group, financial institution, etc.) that transmits electronic data to, or receives electronic data from, another... | /kaggle/input/edi-db/837I_compguide.pdf | 815189f6dea52a5dd9b38b3bba0f5280 | 815189f6dea52a5dd9b38b3bba0f5280_1 |
Partners to send a test file containing at least 25 claims, which are representative of their practice or services. To begin the testing and certification process, trading partners should complete the J15 Communications and the enrollment form (https: www.cgsmedicare.com parta edi enrollment.html). Once CGS provides th... | /kaggle/input/edi-db/837I_compguide.pdf | 815189f6dea52a5dd9b38b3bba0f5280 | 815189f6dea52a5dd9b38b3bba0f5280_2 |
changed when there are any personnel changes. The submitter ID and Password are required to transmit files to CGS. 5 Contact Information 5.1 EDI Customer Service J15- Part A Home Health Hospice (HHH) Correspondence CGS PO box 20018 Nashville, TN 37202 CMS 837I Version 005010X223A2 Companion Guide 2022 Copyright, CGS Ad... | /kaggle/input/edi-db/837I_compguide.pdf | 815189f6dea52a5dd9b38b3bba0f5280 | 815189f6dea52a5dd9b38b3bba0f5280_3 |
Must not be present. 400 2330D Loop Rule Other Payer Operating Physician - Must not be present. 404 2330E Loop Rule Other Payer Other Operating Physician - Must not be present. 408 2330F Loop Rule Other Payer Service Facility Location - Must not be present. 412 2330G Loop Rule Other Payer Rendering Provider Name - Must... | /kaggle/input/edi-db/837I_compguide.pdf | 815189f6dea52a5dd9b38b3bba0f5280 | 815189f6dea52a5dd9b38b3bba0f5280_4 |
must be 11 positions in the format of C A AN N A AN N A A N N where C represents a constrained numeric 1 thru 9, A represents alphabetic character A Z but excluding S, L, O, I, B, Z, N represents numeric 0 thru 9, and AN represents either A or N. 118 2010BA DMG02 Subscriber Birth Date - 35 Must not be a future date. 10... | /kaggle/input/edi-db/837I_compguide.pdf | 815189f6dea52a5dd9b38b3bba0f5280 | 815189f6dea52a5dd9b38b3bba0f5280_5 |
Subscriber Name. Note: A hyphen in the table below means N A. Table 21. Loop 2330A Other Subscriber Name Page Loop ID Reference Name Codes Content Length Notes Comments 378 2330A NM105 Other Insured Middle Name - 25 The first position must be alphabetic (A-Z). CMS 837I Version 005010X223A2 Companion Guide 2022 Copyrigh... | /kaggle/input/edi-db/837I_compguide.pdf | 815189f6dea52a5dd9b38b3bba0f5280 | 815189f6dea52a5dd9b38b3bba0f5280_6 |
requirements must be met: EDI Enrollment Form must be submitted or on file. EDI Application Approved Vendor Software or approved Clearinghouse or Billing Service Approved Network Service Vendor Upon approval of the request to exchange files with CGS, a letter will be sent to the requestor. 11.2 Transmission Examples Fi... | /kaggle/input/edi-db/837I_compguide.pdf | 815189f6dea52a5dd9b38b3bba0f5280 | 815189f6dea52a5dd9b38b3bba0f5280_7 |
is situational There will be a segment note addressing use of the loop. 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 7 Any required segments in loops beginning with a situational segment occur only when the loop is used. 837 BLUE CROSS BLUE SHIELD OF... | /kaggle/input/edi-db/MPC_092315-4N___837_Companion_Guide.pdf | 54a54504acc20b0a1ae517e4deceb1a3 | 54a54504acc20b0a1ae517e4deceb1a3_0 |
we will email each registered user the new password. The user must update their server to use the new password. For individual user IDs The Tumbleweed application will display an error message ( login invalid ), indicating that the password has expired after 90 or 365 days. Users must contact the EDI Production Support... | /kaggle/input/edi-db/MPC_092315-4N___837_Companion_Guide.pdf | 54a54504acc20b0a1ae517e4deceb1a3 | 54a54504acc20b0a1ae517e4deceb1a3_1 |
claims in any one transaction set (batch). For testing, we are not able to process a normal day of your production. However, the claims in your test file should simulate claims associated with your normal business. Production claim files Must not exceed 4,999 claims in any one transmission. You may send multiple transm... | /kaggle/input/edi-db/MPC_092315-4N___837_Companion_Guide.pdf | 54a54504acc20b0a1ae517e4deceb1a3 | 54a54504acc20b0a1ae517e4deceb1a3_2 |
20080630 WQ 793 QTY 90 4 QTY AA 2 AMT YU 578 AMT YY 215 HL 3 2 19 1 NM1 85 2 PROVIDER NAME XX NPI TRN 1 2 REF EI 042888373 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 23 QTY QA 1 QTY QC 2 AMT YU 207 AMT YY 215 HL 4 3 PT NM1 QC 1 LASTNAME FIRSTNAME M... | /kaggle/input/edi-db/MPC_092315-4N___837_Companion_Guide.pdf | 54a54504acc20b0a1ae517e4deceb1a3 | 54a54504acc20b0a1ae517e4deceb1a3_3 |
ID number of the billing provider Use the billing provider s 9-digit tax ID number (without dashes) Loop 2000B Subscriber Information 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 30 837P implementation guide data Payer specific data Position Segment ... | /kaggle/input/edi-db/MPC_092315-4N___837_Companion_Guide.pdf | 54a54504acc20b0a1ae517e4deceb1a3 | 54a54504acc20b0a1ae517e4deceb1a3_4 |
qualifier Situational, but required when the location of the health care service is different than that carried in the 2010AA (billing provider) or 2010AB (pay-to provider) loops Use: The name of the service facility where the services were rendered Refer to Appendix B Facility Code Requirements for 837P claims for Blu... | /kaggle/input/edi-db/MPC_092315-4N___837_Companion_Guide.pdf | 54a54504acc20b0a1ae517e4deceb1a3 | 54a54504acc20b0a1ae517e4deceb1a3_5 |
to help you complete the 837I transaction. If you follow these guidelines, we'll be able to process your claims more accurately and efficiently. Control segments 837I implementation guide data Payer specific data Position Segment ID data element number Description 837 Requirements Blue Cross Blue Shield of MA instructi... | /kaggle/input/edi-db/MPC_092315-4N___837_Companion_Guide.pdf | 54a54504acc20b0a1ae517e4deceb1a3 | 54a54504acc20b0a1ae517e4deceb1a3_6 |
of the policy in loop 2010BA. DETAIL DATA 837I implementation guide data Payer specific data Position Segment ID data element number Description 837 requirements Blue Cross instructions Loop 2010BC Payer Name 015 NM1 Individual or organizational name Information about the Payer 015 NM108 Identification code qualifier R... | /kaggle/input/edi-db/MPC_092315-4N___837_Companion_Guide.pdf | 54a54504acc20b0a1ae517e4deceb1a3 | 54a54504acc20b0a1ae517e4deceb1a3_7 |
individual or organizational entity 020 NM109 67 Identification code Required Use: Your submitter ID (the same code as used in ISA06 and 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 55 837D implementation guide data Payer specific data Position Segme... | /kaggle/input/edi-db/MPC_092315-4N___837_Companion_Guide.pdf | 54a54504acc20b0a1ae517e4deceb1a3 | 54a54504acc20b0a1ae517e4deceb1a3_8 |
provider Use the rendering provider s 10- digit NPI 837 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, February 2024 61 837D implementation guide data Payer specific data Position Segment ID data element number Description 837 Requirements Blue Cross instructions 255 PR... | /kaggle/input/edi-db/MPC_092315-4N___837_Companion_Guide.pdf | 54a54504acc20b0a1ae517e4deceb1a3 | 54a54504acc20b0a1ae517e4deceb1a3_9 |
adjudication: NM1 FA 2 FACILITY NAME XX 1234567890 NPI of service site in NM109. N3 STREET ADDRESS service site street address, using standard USPO codes. N4 CITY ST ZIPCD service city, state and zip code. Example: NM1 FA 2 GENERAL HOSPITAL XX 1234567890 N3 123 ANY ST N4 ANYTOWN MA 12345 General Information on special ... | /kaggle/input/edi-db/MPC_092315-4N___837_Companion_Guide.pdf | 54a54504acc20b0a1ae517e4deceb1a3 | 54a54504acc20b0a1ae517e4deceb1a3_10 |
provider in the 2310B loop Submit the NPI (and, optionally, the tax ID) of the provider contracted with Blue Cross to perform the technical service in the rendering (2310B) loop. For each service other than the technical component service, submit the NPI of the rendering provider in the service rendering (2420A) loop. ... | /kaggle/input/edi-db/MPC_092315-4N___837_Companion_Guide.pdf | 54a54504acc20b0a1ae517e4deceb1a3 | 54a54504acc20b0a1ae517e4deceb1a3_11 |
claim Correct a claim that denied for a referral or authorization, if one has been approved We offer more details in our Replacement claim page on Provider Central, so please be sure to review the guide and share it with your IT team services that require additional documentation for review. When submitting for late ch... | /kaggle/input/edi-db/MPC_092315-4N___837_Companion_Guide.pdf | 54a54504acc20b0a1ae517e4deceb1a3 | 54a54504acc20b0a1ae517e4deceb1a3_12 |
be on the claim level (2330B) or on the line level (2430). We typically see inpatient institutional remittance date on the claim level (2330B) and outpatient professional on the line level (2430). A good practice when you re building an MOA segment is to pass the remit date in the 2430 loop. If you are building an MIA ... | /kaggle/input/edi-db/MPC_092315-4N___837_Companion_Guide.pdf | 54a54504acc20b0a1ae517e4deceb1a3 | 54a54504acc20b0a1ae517e4deceb1a3_13 |
Stedi maintains this guide based on public documentation from Anthem. Contact Anthem 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 March 1, 2024 Go to Stedi Network This X12 Transaction Set contains the ... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_0 |
Information Qualifier (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 publi... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_1 |
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 notes The Transact... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_2 |
used CCP Cash Concentration Disbursement plus Addenda (CCD ) (ACH) 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 12 127 Use the CCD format to move money and up to 80 c... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_3 |
use 1 Required TRN-01 481 Trace Type Code Identifier (ID) Required Code identifying which transaction is being referenced 1 Current Transaction Trace Numbers TRN-02 127 Check or EFT Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Re... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_4 |
included in this 835. 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 21 127 1000A Payer Identification Loop Max 1 Required Variants (all may be used) Payee Identificati... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_5 |
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. Example PER CX XXX T... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_6 |
of communication number UR Uniform Resource Locator (URL) PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable Usage notes This is the payer's WEB site URL where providers can find policy and other related information. 1 29 25, ... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_7 |
do not send. Payer should coordinate this process with their Originating Depository Financial Institution (ODFI). Example RDM OL X X Max use 1 Optional RDM-01 756 Report Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent BM By Mail When used, R... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_8 |
summary of non-lab charges. Usage notes See TR3 note 3. TS3-17 782 Total HCPCS Reported Charge Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS317 is the Health Care Financing Administration Common Procedural Coding System (HCPCS) reported charges. Usage notes See TR3 note 3. TS3-18 782 Total HCPCS Pa... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_9 |
number (R) Optional Numeric value of quantity TS214 is total number of non-covered days. Usage notes See TR3 note 2. TS2-15 782 Total MSP Pass-Through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS215 is the total Medicare Secondary Payer (MSP) pass- through amount calculated for a non-Medicare paye... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_10 |
have supporting adjustments reflected in CAS segments at the 2100 (CLP) or 2110 (SVC) loop level with a Claim Adjustment Group (CAS01) code of PR (Patient Responsibility). Use this monetary amount for the payer's statement of the patient responsibility amount for this claim, which can include such items as deductible, ... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_11 |
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 o... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_12 |
Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Option... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_13 |
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 ... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_14 |
other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual GB Other Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_15 |
1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZ... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_16 |
Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Nonpayable Profession... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_17 |
segment and the Group Number of the other insured for that payer is known. 9A Repriced Claim Reference Number 9C Adjusted Repriced Claim Reference Number 28 Employee Identification Number BB Authorization Number Use this qualifier only when supplying an authorization number that was assigned by the adjudication process... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_18 |
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. Example DTM 232 20250130 Variants (all may be used) DTM Claim Received Date DTM Coverage... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_19 |
8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE893C 83 127 Decimal elements will be limited to a maximum length of 10 characters including reported or implied places for cents (impli... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_20 |
and their trading partners. C003-02 234 Adjudicated Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This is the adjudicated procedure code or revenue code as id... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_21 |
1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVC-07 380 Original Units of Service Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC07 is the original submitted un... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_22 |
1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Servic... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_23 |
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 (Nationa... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_24 |
amount B6 Allowed - Actual Allowed amount is the amount the payer deems payable prior to considering patient responsibility. KH Deduction Amount Late Filing Reduction T Tax T2 Total Claim Before Taxes Use this monetary amount for the service charge before taxes. This is only used when there is an applicable tax amount ... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_25 |
Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar 1 29 25, 8:52 PM Anthem 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-paymentadvice-x221a1 01HQWPEZE89AKHP7SZ7YAE89... | /kaggle/input/edi-db/Anthem 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | c4837cb4c69775f8499ce91c4514ac55 | c4837cb4c69775f8499ce91c4514ac55_26 |
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