835 Business Impacts 005010X221A1...New Element UR: Uniform Resource Locator (URL) Usage: Required ....

835 5010A1 Conversion Business Impacts

Title Business impacts in conversion of the 835 transaction to 5010A1

5010A1 Transaction Identifier 005010X221A1

Prepared By

Michael Stevens

Date January 7, 2009

Ingenix Confidential: Unauthorized access, copying, replication, and distribution is prohibited. This document must not be copied in whole or part by

any means, without the written authorization of Ingenix.

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Table of Contents

Table of Contents ............................................................................................................................................2 Description......................................................................................................................................................3 General............................................................................................................................................................3 Conventions ....................................................................................................................................................3 Front Matter and Transaction Usage Changes ................................................................................................4 Data Use by Business Use Section..............................................................................................................4 Loop and Segment changes from 4010A1 to 5010 .....................................................................................5 Segments added in the 5010 standard .....................................................................................................5

Data element changes with business impacts. .................................................................................................6 Interchange Header Changes.......................................................................................................................6 Transaction Header Changes.......................................................................................................................6 Loop 1000A Payer Identification................................................................................................................7 Loop 1000B Payee Identification..............................................................................................................11 Loop 2000 Header Number.......................................................................................................................15 Loop 2100 Claim Payment Information....................................................................................................16 Loop 2110 Service Payment Information..................................................................................................30 Transaction Summary................................................................................................................................40 Interchange Trailer Changes .....................................................................................................................43

Appendices....................................................................................................................................................44 Change Log ...............................................................................................................................................44

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Description

This document provides an assessment of the business impacts of the conversion from the 4010A1 to 5010 standard of the 835 transaction set.

It looks at the Front Matter changes between the 4010A1 Implementation Guide and the 5010 Technical Report 3 (TR3) documents for the 835.

It also looks at code, qualifier and usage changes within the 5010 835 transactions.

General The 5010 HIPAA implementation renames the 4010 implementation guides to ‘Technical Report 3’ documents. This document will refer to the 5010

implementation standards as TR3’s.

Conventions Loops, segments, and elements impacted by the conversion from 4010A1 to 5010 are presented in this document in table format.

The tables show loop, segment, and element usage changes specific to the 835 transaction, and details the changes between the 4010A1 and 5010 standards.

Text highlighted in yellow shows loops, segments, elements and values deleted from the 4010A1 to 5010 standard

Text highlighted in light blue shows loops, segments, elements and values added in the 5010 standard.

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Front Matter and Transaction Usage Changes

Data Use by Business Use Section Information on the business use of the 835 transaction has been moved from section 2.2 of the 4010 implementation guide to section 1.10.2 of the 5010 TR3.

Information on the business use of the 835 transaction has been significantly expanded in the TR3.

1.10.2.1: Balancing

1.10.2.2: Remittance Tracking

1.10.2.3: Reassociation of Dollars and Data

1.10.2.4: Claim Adjustment and Service Adjustment Segment Theory

1.10.2.5: Advance Payments and Reconciliation (New in the TR3)

1.10.2.6: Procedure Code Bundling and Unbundling

1.10.2.7: Predetermination of Benefits

1.10.2.8: Reversals and Corrections

1.10.2.9: Interest and Prompt Payment Discounts

1.10.2.10: Capitation and Related Payments or Adjustments

1.10.2.11: Claim Splitting (Was ‘Definition of a Claim’ in the 4010 IG)

1.10.2.12: Balance Forward Processing (New in the TR3)

1.10.2.13: Secondary Payment Reporting Considerations (New in the TR3)

1.10.2.14: Service Line Issues (New in the TR3)

1.10.2.15: PPOs, Networks and Contract Types (New in the TR3)

1.10.2.16: Post Payment Recovery (New in the TR3)

1.10.2.17: Claim Overpayment Recovery (New in the TR3)

1.10.2.18: Totals within the 835 (New in the TR3)

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Loop and Segment changes from 4010A1 to 5010 This section provides an overview of the loop and segment changes between the 4010A1 and 5010 versions of the 835. A detailed listing of segment/element

impacts for each of these changes is listed in the next section of this document.

Segments added in the 5010 standard

This is a list of segments added to existing loops in the 5010 standard.

Loop Segment Segment Name

1000A PER Payer Technical Contact Information

1000A PER Payer Web Site

1000B RDM Remittance Delivery Method

2100 NM1 Other Subscriber Name

2110 REF Healthcare Policy Identification

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Data element changes with business impacts. This section lists all data elements that have changed, and analyzes business impacts for those changes.

Interchange Header Changes

Loop Segment /

Element Element Name

4010

Valid Values

and

Descriptions

5010

Valid Values

And

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

N/A ISA Segment

Repeat: Not specified

Segment Repeat: 1

Segment Repeat deleted

Change in Segment Repeat

N/A ISA11

4010: Interchange Control Version Number 5010 : Repetition Separator U

Defined between trading partners

This element is a delimiter in the 5010 standard, and must not occur in data.

N/A ISA12 Interchange Control Version Number

00401 00501

N/A GS Segment

Repeat: Not specified

Segment Repeat: 1

Segment Repeat deleted

Change in Segment Repeat

N/A GS08 Version Release / Industry Code Identifier

004010X091A1 005010X221 005010X221A1

Transaction Header Changes

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

N/A BPR02 Financial Information Monetary Amount

TR3 Notes: Use BPR02 for the total payment amount for this 837. The total payment amount for this 835 cannot exceed

eleven characters, including decimals (99999999.99). Although the value can be zero, the 837 cannot be issued for less than zero dollars.

N/A TRN02 Reassociation Trace Number Check or EFT Trace Number

Length: 1 - 30 Length: 1 - 50 Maximum length increase from 30 - 50

N/A TRN02

Reassociation Trace Number Originating Company Supplemental Code


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N/A CUR03 Foreign Currency Information Exchange Rate

Element Deleted

N/A REF02 Receiver Identification Receiver Identification


N/A REF02 Version Identification Version Identification Code


Loop 1000A Payer Identification

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

1000A N102 Payer Identification Name

Usage: Situational

Usage: Required

Usage changed from situational to required

1000A N402 Payer City, State, Zip Code State or Province code

Usage: Required

Usage: Situational

Segment N4 now supports international addresses. Changed from required to situational TR3 Usage Rule:

SITUATIONAL RULE: Required when address is in the

United States of America, including its territories, or

Canada. If not required by this implementation guide,

do not send.

1000A N403 Payer City, State, Zip Code Postal code

Usage: Required

Usage: Situational

Changed from required to situational TR3 Usage Rule:

SITUATIONAL RULE: Required when the address is in the


Canada, or when a postal code exists for the country

in N404. If not required by this implementation guide,

do not send.

1000A N404 Payer City, State, Zip Code Country Code

Usage: Not Used

New Element

Usage: Situational TR3 Usage Rule:

SITUATIONAL RULE: Required when the address is

outside the United States of America. If not required

by this implementation guide, do not send.

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

1000A N407 Payer City, State, Zip Code Country Subdivision Code

New Element


SITUATIONAL RULE: Required when the address is not in

the United States of America, including its territories,

or Canada, and the country in N404 has

administrative subdivisions such as but not limited

to states, provinces, cantons, etc. If not required by

this implementation guide, do not send.

1000A REF02 Additional Payer Identification Additional Payer Identifier


1000A PER04 PER06 PER08

Payer Business Contact Information Contact Number

Length: 1 - 80 Length: 1 - 256

Maximum length increase from 80 – 256 Length increase will support email addresses longer than 80 bytes when sent.

1000A PER Payer Technical Contact Information New Segment

Usage: Required TR3 Usage Rule:

Required to report technical contact information for

this remittance advice.

1000A PER01 Payer Technical Contact Information Contact Function Code

New Element BL: Technical

Department

Usage: Required

1000A PER02 Payer Technical Contact Information Payer Technical Contact Name

New Element Length: 1 -

60


SITUATIONAL RULE: Required when it is necessary to

identify an individual or other contact point to

discuss technical information related to this

transaction. If not required by this implementation

guide, do not send.

Use this data element when the name of the

individual to contact is not already defined or is

different than the name within the prior name

segment (e.g. N1 or NM1).

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

1000A PER03 Payer Technical Contact Information Communication Number Qualifier

New Element EM:

Electronic Mail

TE: Telephone

UR: Uniform Resource Locator (URL)


SITUATIONAL RULE: Required when a contact

communication number is to be transmitted. If not

required by this implementation guide, do not send.

1000A PER04

Payer Technical Contact Information Payer Contact Communication Number

New Element Length: 1 - 256


SITUATIONAL RULE: Required when a contact

communication number is to be transmitted. If not



New Element EM:

Electronic Mail

EX: Telephone Extension

FX: Facsimile TE:

Telephone

UR: Uniform Resource Locator (URL)


SITUATIONAL RULE: Required when a second

communication contact number is needed. If not


1000A PER06




SITUATIONAL RULE: Required when an extension applies

to the previous communications contact number

(PER06). If not required by this implementation

guide, do not send.

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes


New Element EM:

Electronic Mail

EX: Telephone Extension

FX: Facsimile UR: Uniform

Resource Locator (URL)


SITUATIONAL RULE: Required when a second

communication contact number is needed. If not


1000A PER08




SITUATIONAL RULE: Required when an extension applies

to the previous communications contact number

(PER06). If not required by this implementation

guide, do not send.

1000A PER Payer Web Site New Segment

Usage: Situational

Situational Rule in 5010A1:

Required when any 2110 loop Healthcare Policy REF

Segment is used.

If not required by this implementation guide, do not

send.

New TR3 Note:

This is a direct link to the policy location of the un-

secure website.

1000A PER01 Payer Web Site Contact Function Code

New Element IC:

Information Contact

Usage: Required

1000A PER03 Payer Web Site Communication Number Qualifier

New Element UR: Uniform

Resource Locator (URL)

Usage: Required

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

1000A PER04 Payer Web Site New Element Length: 1 - 256

Usage: Required TR3 Usage Rule:

This is the payer’s WEB site URL where providers

can find policy and other related information.

Loop 1000B Payee Identification

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

1000B N102 Payee Identification Payee Name

Usage: Situational

Usage: Required

Usage changed from situational to required

1000B N103 Payee Identification Identification Code Qualifier

FI: Federal Taxpayer's Identification Number

XX: Health

Care Financing Administration National Provider Identifier

FI: Federal Taxpayer's Identification Number

XV: Centers for Medicare and Medicaid Services PlanID

XX: Health Care Financing Administration National Provider Identifier

Code Added TR3 Usage Notes for value ‘XV’

This is REQUIRED when the National Health Plan

Identifier is mandated for use and the payee is a

health plan. This only applies in cases of post

payment recovery. See section 1.10.2.16 (Post

Payment Recovery) for further information.

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

1000B N4 Payee City, State, Zip Code

Usage: Required

Usage: Situational

Situational Rule in 5010A1: Required when the sender needs to communicate the payee address to a transaction receiver, e.g., a VAN or a clearinghouse. If not required by this implementation guide, may be provided at the sender’s discretion, but cannot be required by the receiver.

1000B N402 Payee City, State, Zip Code State or Province code

Usage: Required Usage: Situational

Segment N4 now supports international addresses. Changed from required to situational TR3 Usage Rule:

SITUATIONAL RULE: Required when address is in the


Canada. If not required by this implementation

guide, do not send.

1000B N403 Payee City, State, Zip Code Postal code

Usage: Required Usage: Situational

Changed from required to situational TR3 Usage Rule:

SITUATIONAL RULE: Required when the address is in the


Canada, or when a postal code exists for the

country in N404. If not required by this

implementation guide, do not send.

1000B N407 Payee City, State, Zip Code Country Subdivision Code

New Element


SITUATIONAL RULE: Required when the address is not in

the United States of America, including its

territories, or Canada, and the country in N404 has

administrative subdivisions such as but not limited

to states, provinces, cantons, etc. If not required by

this implementation guide, do not send.

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

1000B REF01 Payee Additional Identification Reference Identification Qualifier

0B: State License Number

1A: Blue Cross Provider Number

1B: Blue Shield Provider Number

1C: Medicare Provider Number

1D: Medicaid Provider Number

1E: Dentist License Number

1F: Anesthesia License Number

1G: Provider UPIN Number

1H: CHAMPUS Identification Number

D3: National Association of Boards of Pharmacy Number

G2: Provider Commercial Number

N5: Provider Plan Network Identification Number

PQ: Payee Identification

TJ: Federal Taxpayer's Identification


D3: National

Association of Boards of Pharmacy Number

PQ: Payee

Identification

TJ: Federal Taxpayer's Identification Number

Codes Deleted TR3 usage notes on value ‘TJ’

This information must be in the N1 segment unless

the National Provider ID or the National Health Plan

Identifier was used in N103/04. For individual

providers as payees, use this number to represent

the Social Security Number. TJ also represents the

Employer Identification Number (EIN). According to

the IRS, TIN and EIN can be used interchangeably.

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

1000B REF02 Payee Additional Identification Additional Payee Identifier


1000B RDM Remittance Delivery Method

New Segment Usage: Situational

TR3 Usage Rule:

Required when BPR01 = U or X; and the remittance

is to be sent separately from the payment. The payer

is responsible to provide the bank with the

instructions on how to deliver the remittance

information, if not required by this implementation

guide, do not send.

TR3 Notes:

1. Payer should coordinate this process with their

Originating Depository Financial Institution (ODFI).

1000B RDM01 Remittance Delivery Method Report Delivery Method

New Element Usage: Required BM: By Mail EM: E-Mail FT: File

Transfer OL: On-line

1000B RDM02 Remittance Delivery Method Name

New Element Usage: Situational Length: 1 – 60

TR3 Usage Rule:

SITUATIONAL RULE: Required when RDM01 = BM. If not


When BM is used, the remittance information will be

mailed to the attention of this person at the payee’s

address identified in this 1000B loop.

1000B RDM03 Remittance Delivery Method Communications Number

New Element Usage: Situational Length: 1 –

256

TR3 Usage Rule:

SITUATIONAL RULE: Required when RDM01 equals EM,

FT, or OL. If not required by this implementation

guide, do not send.

Contains URL web address or e-mail address.

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Loop 2000 Header Number

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2000 TS301 Provider Summary Information Provider Identifier


2000 TS306 Provider Summary Information Total Covered Charge Amount

Element Deleted

2000 TS307 Provider Summary Information Total Noncovered Charge Amount

Element Deleted

2000 TS308 Provider Summary Information Total Denied Charge Amount

Element Deleted

2000 TS309 Provider Summary Information Total Provider Payment Amount

Element Deleted

2000 TS310 Provider Summary Information Total Interest Amount

Element Deleted

2000 TS311

Provider Summary Information Total Contractual Adjustment Amount

Element Deleted

2000 TS312

Provider Summary Information Total Gramm-Rudman Reduction Amount

Element Deleted

2000 TS314 Provider Summary Information Total Blood Deductible Amount

Element Deleted

2000 TS316 Provider Summary Information Total Coinsurance Amount

Element Deleted

2000 TS319 Provider Summary Information Total Deductible Amount

Element Deleted

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Loop 2100 Claim Payment Information

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2100 CLP02 Claim Payment Information Claim Status Code

1: Processed as Primary

2: Processed as Secondary

3: Processed as Tertiary

4: Denied 5: Pended 10: Received,

but not in process

13: Suspended 15: Suspended

- investigation with field

16: Suspended - return with material

17: Suspended - review pending

19: Processed as Primary, Forwarded to Additional Payer(s)

20: Processed as Secondary, Forwarded to Additional Payer(s)

21: Processed as Tertiary, Forwarded to Additional Payer(s)

22: Reversal of Previous Payment

23: Not Our Claim, Forwarded to Additional Payer(s)

25:Predetermination Pricing Only - No Payment

27: Reviewed

1: Processed as Primary

2: Processed

as

Secondary

3: Processed

as Tertiary

4: Denied 19: Processed as

Primary,

Forwarded

to Additional Payer(s) 20: Processed as Secondary, Forwarded to Additional Payer(s) 21: Processed as Tertiary, Forwarded to Additional

Codes Deleted TR3 Usage rules for values ‘19’, ‘20’, and ‘21’

When this code is used, the Crossover Carrier Name

NM1 segment is required.

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2100 CLP06 Claim Payment Information Claim Status Code

12: Preferred Provider Organization (PPO)

13: Point of Service (POS)

14: Exclusive Provider Organization (EPO)

15: Indemnity Insurance

16: Health Maintenance Organization (HMO) Medicare Risk

AM: Automobile

Medical CH: Champus DS: Disability HM: Health

Maintenance Organization

LM: Liability Medical

MA: Medicare Part A

MB: Medicare Part B

MC: Medicaid OF: Other

Federal Program

TV: Title V VA: Veterans

Affairs Plan WC: Workers'

Compensation Health Claim

12: Preferred Provider Organization (PPO)

13: Point of Service (POS)

14: Exclusive Provider Organization (EPO)

15: Indemnity Insurance

16: Health Maintenance Organization (HMO) Medicare Risk

17: Dental Maintenance Organization

AM: Automobile Medical

CH: Champus DS: Disability HM: Health

Maintenance

Organization

LM: Liability Medical

MA: Medicare Part A

MB: Medicare Part B

MC: Medicaid OF: Other

Federal Program

TV: Title V VA: Veterans

Codes Added

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2100 CLP07 Claim Payment Information Payer Claim Control Number

Usage: Situational

Length: 1 - 30

Usage: Required Length: 1 - 50

Usage changed from situational to required Maximum length increase from 30 – 50

2100 CAS01 Claim Adjustment Claim Adjustment Group Code

CO: Contractual Obligations

CR: Correction and Reversals

OA: Other adjustments

PI: Payor Initiated Reductions

PR: Patient

Responsibility

CO: Contractual

Obligations

OA: Other

adjustments

PI: Payor Initiated

Reductions

PR: Patient

Responsibility

Code Deleted TR3 Usage Note for value ‘OA’:

Avoid using the Other Adjustment Group Code (OA)

except for business situations described in sections

1.10.2.6, 1.10.2.7 and 1.10.2.13 (of the 835 TR3).

2100 NM1 Patient Name

TR3 Notes in 5010A1: This segment must provide the information form the original claim. For example, when the claim is submitted as an ASC X12 837 transaction, this is the 2010CA loop NM1 Patient Name Segment unless not present on the original claim, then it is the 2010BA loop NM1 Subscriber name segment. The corrected Patient/Insured Name NM1 segment identifies the adjudicated Insured Name and ID information if different than what was submitted on the claim.

2100 NM103 Patient Name Patient Last Name

Usage: Required Length: 1 – 35

Usage: Situational Length: 1 – 60

Usage changed from required to situational Maximum length changed from 35 - 60 TR3 Usage Rule:

SITUATIONAL RULE: Required for all claims that are not

Retail Pharmacy claims or for Retail Pharmacy

claims when the information is known. If not


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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2100 NM104 Patient Name Patient First Name

Usage: Required Length: 1 – 25

Usage: Situational Length: 1 – 35

Usage changed from required to situational Maximum length changed from 25 – 35 TR3 Usage Rule:

SITUATIONAL RULE: Required when the patient has a

first name and it is known. If not required by this


2100 NM108 Patient Name Identification Code Qualifier

34: Social Security Number

HN: Health Insurance Claim (HIC) Number

MI: Member

Identification Number

MR: Medicaid Recipient Identification Number


HN: Health Insurance Claim (HIC) Number

II: Standard Unique Health Identifier for each Individual in the United States

MI: Member


MR: Medicaid Recipient


New Code TR3 Usage notes for value ‘II’

Use this code if mandated in a final Federal Rule.

2100 NM1 Insured Name

Situational Rule in 5010A1: Required when the original claim reported the insured or subscriber (for example 837 2010BA loop Subscriber Name NM1 Segment) that is different from the patient. If not required by this implementation guide, do not send. TR3 Notes in 5010A1: This segment contains the same information as reported on the claim (for example 837 2010BA loop Subscriber Name NM1 Segment when the patient was reported in the 2010CA loop Patient Name NM1 Segment).

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2100 NM103 Insured Name Insured Last Name

Length: 1 - 35 Length: 1 – 60 Maximum length changed from 35 – 60

2100 NM104 Insured Name Insured First Name


2100 NM108 Insured Name Identification Code Qualifier


HN: Health

Insurance Claim (HIC) Number

MI: Member


FI: Federal

Taxpayer’s


II: Standard

Unique Health

Identifier for each Individual in the United States

MI: Member


Codes Deleted Codes Added TR3 Usage notes for value ‘FI’

Not Used when NM102=1. TR3 Usage notes for value ‘II’


2100 NM103

Corrected Patient/Insured Name Corrected Patient/Insured Last Name


2100 NM104

Corrected Patient/Insured Name Corrected Patient/Insured First Name


2100 NM103 Service Provider Name Service Provider Last Name


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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2100 NM104 Service Provider Name Service Provider First Name


2100 NM103 Crossover Carrier Name Crossover Carrier Name


2100 NM103 Corrected Priority Payer Name Corrected Priority Payer Name


2100 NM1 Other Subscriber Name New Segment


Situational Rule: Required when a corrected priority

payer has been identified in another NM1 segment

AND the name or ID of the other subscriber is

known. If not required by this implementation guide,

do not send.

011030

TR3 Notes: 1. This is the name and ID number of the

other subscriber when a corrected priority payer has

been identified. When used, either the name or ID

must be supplied.

2100 NM101 Other Subscriber Name Entity Identifier Code

New Element GB: Other

Insured

Usage: Required

2100 NM102 Other Subscriber Name Entity Type Qualifier

New Element: 1: Person 2: Non-Person Entity

Usage: Required

2100 NM103 Other Subscriber Name Other Subscriber Last Name

New Element Length: 1-60


SITUATIONAL RULE: Required when known or when

NM109 is not present. If not required by this


At least one of NM103 or NM109 must be present.

2100 NM104 Other Subscriber Name Other Subscriber First Name



SITUATIONAL RULE: Required when the Other

Subscriber is a person (NM102=1), NM103 is present

and the first name is known. If not required by this


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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2100 NM105 Other Subscriber Name Other Subscriber Middle Name




Subscriber is a person (NM102=1) and the middle

name or initial is known. If not required by this


2100 NM107 Other Subscriber Name Other Subscriber Name Suffix




Subscriber is a person (NM102=1), the information

is known and this information is necessary for

identification of the individual. If not required by this


2100 NM108 Other Subscriber Name Identification Code Qualifier

New Element FI: Federal

Taxpayer’s


II: Standard Unique Health Identifier for each Individual in the United States

MI: Member



SITUATIONAL RULE: Required when NM109 is known. If

not required by this implementation guide, do not

send. TR3 Usage notes for value ‘FI’

Not Used when NM102=1. TR3 Usage notes for value ‘II’


2100 NM109 Other Subscriber Name Other Subscriber Identifier

New Element

Usage Situational. TR3 Usage Rule:

SITUATIONAL RULE: Required when known or when

NM103 is not present. If not required by this


At least one of NM103 or NM109 must be present.

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2100 MIA02 Inpatient Adjudication Information PPS Operating Outlier Amount

Defined as Quantity Length 1 – 15

Monetary Amount Length: 1 - 18

Length and element type change

2100 MIA05 Inpatient Adjudication Information Claim Payment Remark Code

Length: 1 – 30 Length: 1 - 50 Maximum length increase from 30 – 50 Valid values are from external codeset 411, should have no business impact.

2100

MIA20 MIA21 MIA22 MIA23

Inpatient Adjudication Information Remark Code


2100

MOA03 MOA04 MOA05 MOA06 MOA07

Inpatient Adjudication Information Claim Payment Remark Code


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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2100 REF01 Other Claim Related Identification Reference Identification Qualifier

1L: Group or Policy Number

1W: Member Identification Number

9A: Repriced

Claim Reference Number

9C: Adjusted Repriced Claim Reference Number

A6: Employee Identification Number

BB: Authorization Number

CE: Class of

Contract Code

EA: Medical Record Identification Number

F8: Original Reference Number

G1: Prior

Authorization Number

G3: Predetermination

of Benefits Identification Number

IG: Insurance

Policy Number

SY: Social Security Number

1L: Group or Policy Number

1W: Member


28: Employee


6P: Group Number

9A: Repriced Claim Reference Number

9C: Adjusted Repriced Claim Reference Number

BB: Authorization Number CE: Class of

Contract Code

EA: Medical Record


F8: Original Reference Number G1: Prior


G3: Predeterminati

on of

Code Deleted Codes Added. The TR3 adds usage notes for some of the specified internal code values. Usage Note for value ‘1L’

Use this code when conveying the Group Number in

REF02.

Usage Note for value ‘6P’

This is the Other Insured Group Number. This is

required when a Corrected Priority Payer is

identified in the NM1 segment and the Group

Number of the other insured for that payer is known.

Usage Note for value ‘BB’

Use this qualifier only when supplying an

authorization number that was assigned by the

adjudication process and was not provided prior to

the services. Do not use this qualifier when

reporting the same number as reported in the claim

as the prior authorization or pre-authorization

number.

Usage Note for value ‘CE’

See section 1.10.2.15 for information on the use of

Class of Contract Code.

Usage Note for value ‘F8’

When this is a correction claim and CLP07 does not

equal the CLP07 value from the original claim

payment, one iteration of this REF segment using

this qualifier is REQUIRED to identify the original

claim CLP07 value in REF02. See section 1.10.2.8,

Reversals and Corrections, for additional

information.

Usage Note for value ‘G1’

Use this qualifier when reporting the number

received with the original claim as a

preauthorization number (in the 837 that was at

table 2, position 180, REF segment, using the same

qualifier of G1).

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2100 REF02 Other Claim Related Identification Other Claim Related Identifier

Length: 1 - 30 Length: 1 - 50 Maximum length increase from 30 – 50

2100 REF01 Rendering Provider Information Reference Identification Qualifier

1A: Blue Cross

Provider Number

1B: Blue Shield

Provider Number

1C: Medicare

Provider Number




D3: National

Association of Boards of Pharmacy Number









1J: Facility ID Number

D3: National

Association

of Boards of

Pharmacy Number

G2: Provider

Commercial Number

LU: Location Number

Codes Added

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2100 PER03 Claim Contact Information Communications Number Qualifier

Usage: Situational

Usage: Required

Usage change from situational to required

2100 PER04 Claim Contact Information Communication Number

Usage: Situational

Length: 1 – 80

Usage: Required Length: 1 –

256

Usage change from situational to required Maximum Length changed from 80 – 256

2100 PER06 PER08

Claim Contact Information Communication Number

Length: 1 – 80 Length: 1 –

256 Maximum Length changed from 80 – 256

2100 AMT Claim Supplemental Information Segment Repeat:

14 Segment Repeat: 13

Maximum segment repeat changed from 14 to 13.

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2100 AMT01 Claim Supplemental Information Amount Qualifier Code

AU: Coverage Amount

D8: Discount Amount

DY: Per Day Limit

F5: Patient Amount Paid

I: Interest NL: Negative

Ledger Balance

T: Tax T2: Total Claim

Before Taxes

ZK: Federal

Medicare or Medicaid Payment Mandate - Category 1

ZL: Federal


ZM: Federal


ZN: Federal


ZO: Federal


AU: Coverage Amount

D8: Discount Amount

DY: Per Day Limit

F5: Patient Amount Paid

I: Interest NL: Negative

Ledger Balance

T: Tax T2: Total

Claim Before Taxes

ZK: Federal Medicare or Medicaid Payment Mandate –

Category 1

ZL: Federal Medicare or Medicaid Payment Mandate –

Category 2

ZM: Federal Medicare or Medicaid Payment Mandate –

Category 3

ZN: Federal Medicare or Medicaid Payment Mandate –

Category 4 ZO: Federal

Code Deleted

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

2100 QTY01

Claim Supplemental Information Quantity Quantity Qualifier

CA: Covered - Actual

CD: Co-insured - Actual

LA: Life-time

Reserve - Actual

LE: Life-time Reserve - Estimated

NA: Number of Non-covered Days

NE: Non-Covered - Estimated

NR: Not Replaced Blood Units

OU: Outlier

Days PS: Prescription VS: Visits ZK: Federal


ZL: Federal


ZM: Federal


ZN: Federal

Medicare or Medicaid Payment Mandate -

CA: Covered - Actual

CD: Co-insured - Actual

LA: Life-time Reserve - Actual

LE: Life-time Reserve - Estimated

NE: Non-

Covered - Estimated

NR: Not Replaced Blood Units

OU: Outlier Days

PS:Prescription VS: Visits ZK: Federal

Medicare or Medicaid Payment Mandate –

Category 1

ZL: Federal Medicare or Medicaid Payment Mandate –

Category 2

ZM: Federal Medicare or Medicaid Payment Mandate - Category

Code Deleted

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Loop 2110 Service Payment Information

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Description

s

Notes

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Description

s

Notes

2110 SVC01-1

Service Payment Information Composite Medical Procedure Identifier – Product/Service ID Qualifier

AD: American Dental Association Codes

ER: Jurisdiction Specific Procedure and Supply Codes

HC: Health Care Financing

Administration Common Procedural Coding System (HCPCS) Codes

ID: International

Classification of Diseases Clinical Modification (ICD-9-CM) - Procedure

IV: Home Infusion EDI Coalition (HIEC) Product/

Service Code N4: National Drug

Code in 5-4-2 Format

NU: National Uniform Billing Committee (NUBC) UB92 Codes RB: National

Uniform Billing Committee





HP: Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code

IV: Home Infusion

EDI Coalition (HIEC) Product/



N6:National Health Related Item Code in 4-6 Format

NU:National Uniform Billing Committee (NUBC) UB92 Codes

UI: U.P.C. Consumer

TR3 Usage Notes: Value ‘HP:

Medicare uses this code to reflect the Skilled

Nursing Facility Group as well as the Home

Health

Agency Outpatient Prospective Payment System.

Value IV:

This code set is not allowed for use under HIPAA

at the time of this writing. The qualifier can only

be

used 1) If a new rule names HIEC as an allowable

code set under HIPAA. 2) For Property & Casualty

claims/encounters that are not covered under

HIPAA.

Value N6:



be

used 1) If a new rule names National Health

Related Item Code in 4-6 Format Codes as an

allowable code

set under HIPAA. 2) For Property & Casualty


HIPAA.

Value ‘UI’



be

used 1) If a new rule names U.P.C. Consumer

Package Code (1-5-5) Codes as an allowable



HIPAA.

Value ‘WK’



be

used in transactions covered under HIPAA by

parties registered in the pilot project and their

trading partners.

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Description

s

Notes

2110 SVC01-7

Service Payment Information Composite Medical Procedure Identifier – Description

Element Deleted

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Description

s

Notes

2110 SVC06-1

Service Payment Information Composite Medical Procedure Identifier – Product/Service ID Qualifier





ID: International

Classification of Diseases Clinical Modification (ICD-9-CM) - Procedure

IV: Home Infusion EDI Coalition (HIEC) Product/



NU: National Uniform Billing Committee (NUBC) UB92 Codes

RB: National Uniform Billing Committee (NUBC) UB82 Codes

ZZ: Mutually





HP: Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code

IV: Home Infusion

EDI Coalition (HIEC) Product/ Service Code

N4: National Drug Code in 5-4-2 Format

NU: National Uniform Billing Committee (NUBC) UB92 Codes

WK: Advanced

TR3 Usage Notes: Value ‘HP:

Medicare uses this code to reflect the Skilled

Nursing Facility Group as well as the Home

Health

Agency Outpatient Prospective Payment System.

Value IV:



be

used 1) If a new rule names HIEC as an allowable



HIPAA.

Value ‘WK’



be

used in transactions covered under HIPAA by

parties registered in the pilot project and their

trading partners.

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Description

s

Notes

2110 CAS01 Service Adjustment Service Adjustment Group Code


CR: Correction and Reversals

OA: Other adjustments

PI: Payor Initiated Reductions

PR: Patient Responsibility


OA: Other

adjustments PI: Payor Initiated

Reductions PR: Patient

Responsibility

Code Deleted TR3 Usage Note for value ‘OA’:

Avoid using the Other Adjustment Group Code

(OA)

except for business situations described in

sections

1.10.2.6, 1.10.2.7 and 1.10.2.13 (of the 835 TR3).

2110 REF Service Identification Segment Repeat: 7 Segment Repeat: 8

In the 5010 standard, the documentation for the Line Item Control Number has been broken out into its own segment. Maximum segment repeat changed from 7 to 8.

2110 REF01 Service Identification Reference Identification Qualifier

1S: Ambulatory Patient Group (APG) Number

6R: Provider Control Number

BB: Authorization

Number E9: Attachment

Code G1: Prior


G3:Predetermination of Benefits Identification Number

LU: Location Number

RB: Rate code number

1S: Ambulatory Patient Group (APG) Number

APC: Ambulatory

Payment Classification

BB: Authorization Number

E9: Attachment Code

G1: Prior Authorization Number

G3:Predetermination of Benefits Identification Number

LU: Location Number

RB: Rate code number

Code Added Value ‘6R’ assigned to separate REF segment in IG (Documented below)

2110 REF02 Service Identification Reference Identification


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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Description

s

Notes

2110 REF Line Item Control Number

This segment existed as a part of the Service Identification segment in the 4010 standard, and is documented as a separate segment in the 5010 standard.

2110 REF01 Line Item Control Number Reference Identification Qualifier

6R: Provider Control Number

Value ‘6R’ assigned to separate REF segment in IG

2110 REF02 Line Item Control Number Reference Identification


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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Description

s

Notes

2110 REF01 Rendering Provider Reference Identification Qualifier

1A: Blue Cross

Provider Number







HPI: Health Care

Financing Administration National Provider Identifier











D3: National Council for Prescription Drug Programs Pharmacy Number


HPI: Health Care Financing Administration National Provider Identifier



Codes Added

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Description

s

Notes

2110 REF Healthcare Policy Identification New Segment

Usage: Situational TR3 Usage Rule: Situational Rule: Required when; The payment is adjusted in accordance with the Payer’s published Healthcare Policy Code list and

- A Claim Adjustment Reason Code identified by the notation, “refer to 835 Healthcare Policy identification segment”, in the Claim Adjustment Reason Code List is present in a related CAS segment and

- The payer has a published enumerated healthcare policy code list available to healthcare providers via an un-secure

public website and the payer wishes to

supply this policy detail to reduce

provider requires. If not required by this

implementation guide, may be provided

at the sender’s discretion, but cannot

be required by the receiver. TR3 Notes: 1. Healthcare Policy - A clinical/statutory rule use to determine claim adjudication that cannot be explained by the sole use of a claim adjustment reason code in the CAS segment and Remittance Advise Remark code when appropriate. 2. The term Healthcare Policy is intended to include Medical Review Policy, Dental Policy Review, Property and Casualty Policies, Workers Comp Policies and Pharmacy Policies for example Medicare LMRP’s.( Local Medicare Review policies) and NCD (National Coverage Determinations). 3. This policy segment must not be used to provide a proprietary explanation code or reason for adjustment. 4. Supply the Healthcare policy identifier in REF02 as provided by the payer’s published Healthcare policy code list. This policy code will be used to explain the policy used to process the claim which resulted in the adjusted payment. 5. If this segment is used, the PER (Payer Web Site) segment is required to provide an un-secure WEB contact point where the provider can access the payer’s enumerated, published healthcare policy.

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Description

s

Notes

2110 REF01 Healthcare Policy Identification Reference Identification Qualifier

New Element 0K: Policy Form Identifying Number

Usage: Required

2110 REF02 Healthcare Policy Identification Healthcare Policy Identifier


Usage: Required

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Description

s

Notes

2110 AMT01 Service Supplemental Amount Amount Qualifier Code

Segment Repeat: 12 B6: Allowed -

Actual DY: Per Day Limit KH: Deduction

Amount NE: Net Billed T: Tax T2: Total Claim

Before Taxes ZK: Federal


ZL: Federal Medicare or Medicaid Payment Mandate - Category 2

ZM: 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

Segment Repeat: 9 B6: Allowed -

Actual KH: Deduction

Amount T: Tax T2: Total Claim

Before Taxes ZK: Federal






Maximum segment repeat changed from 12 to 9. Codes Deleted

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Description

s

Notes

2110 QTY01 Service Supplemental Quantity Quantity Qualifier

NE: Non-Covered - Estimated

ZK: Federal Medicare or Medicaid Payment Mandate - Category 1





ZK: Federal






Code Deleted

Transaction Summary

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Description

s

Notes

N/A

PLB03-1 PLB05-1 PLB07-1 PLB09-1 PLB11-1

Provider Adjustment Adjustment Identifier – Adjustment Reason Code

50: Late Charge 51: Interest

Penalty Charge

72: Authorized

50: Late Charge 51: Interest

Penalty Charge

72: Authorized

Code Added Code Deleted Value ‘HM’ replaces value ‘ZZ’ for identifying Hemophilia Clotting Factor Supplement

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Description

s

Notes

PLB13-1 Return 90: Early Payment

Allowance AH: Origination

Fee AM: Applied to

Borrower's Account

AP: Acceleration of Benefits

B2: Rebate B3: Recovery

Allowance BD: Bad Debt

Adjustment BN: Bonus C5: Temporary

Allowance CR: Capitation

Interest CS: Adjustment CT: Capitation

Payment CV: Capital

Passthru CW: Certified

Registered Nurse Anesthetist Passthru

DM: Direct Medical Education Passthru

E3: Withholding FB: Forwarding

Balance FC: Fund

Allocation GO: Graduate

Medical Education Passthru

IP: Incentive

Premium

Return 90: Early Payment

Allowance AH: Origination

Fee AM: Applied to

Borrower's Account

AP: Acceleration of Benefits

B2: Rebate B3: Recovery

Allowance BD: Bad Debt

Adjustment BN: Bonus C5: Temporary

Allowance CR: Capitation

Interest CS: Adjustment CT: Capitation

Payment CV: Capital

Passthru CW: Certified

Registered Nurse Anesthetist Passthru

DM: Direct Medical Education Passthru

E3: Withholding FB: Forwarding

Balance FC: Fund

Allocation GO: Graduate

Medical Education Passthru

HM: Hemophilia Clotting Factor Supplement

IP: Incentive Premium

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Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Description

s

Notes

Payment IR: Internal

Revenue Service Withholding

IS: Interim Settlement

J1: Nonreimbursable

L3: Penalty L6: Interest Owed LE: Levy LS: Lump Sum OA: Organ

Acquisition Passthru

OB: Offset for Affiliated Providers

PI: Periodic Interim Payment

PL: Payment Final RA: Retro-activity

Adjustment RE: Return on

Equity SL: Student Loan

Repayment TL: Third Party

Liability WO: Overpayment

Recovery WU: Unspecified

Recovery ZZ: Mutually

Defined

Payment IR: Internal

Revenue Service Withholding

IS: Interim Settlement

J1: Nonreimbursable

L3: Penalty L6: Interest Owed LE: Levy LS: Lump Sum OA: Organ

Acquisition Passthru

OB: Offset for Affiliated Providers

PI: Periodic Interim Payment

PL: Payment Final RA: Retro-activity

Adjustment RE: Return on

Equity SL: Student Loan

Repayment TL: Third Party

Liability WO: Overpayment

Recovery WU: Unspecified

Recovery

N/A

PLB01 PLB03-2 PLB05-2 PLB07-2 PLB09-2 PLB11-2 PLB13-2

Provider Adjustment Provider Adjustment Identifier


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Interchange Trailer Changes

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A1

Valid Values

and

Descriptions

Notes

N/A GE Segment Repeat: Not specified

Segment Repeat: 1 Segment Repeat deleted

N/A IEA Segment Repeat: Not specified

Segment Repeat: 1 Segment Repeat deleted

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Appendices

Change Log

Version Description Author Date 1.00 Initial Release J. Michael Stevens January 7, 2009

1.10 Correction of errors/typos

Format standardization with other 5010 Business Impacts

documents

J. Michael Stevens June 23, 2009

1.20 Updated in correspondent to latest 835 Data Transformation

Analysis for following loops/segments/elements:

2100 CLP07

2110 REF

2110 AMT

2110PLB01

Sun Park May 14, 2010

1.21 ISA & IEA, GS & GE segment repeat change added

Sun Park May 20, 2010

2.00 Added a new column for “5010A1 Valid Values and Description” Sun Park August 17, 2010

2.01 ISA – segment repeat count deleted in 5010A1

GS – segment repeat count deleted in 5010A1

GS08 – Functional Group Header Version / Release / Industry

Identifier Code updated

BPR02 – Financial Information Monetary Amount TR3 Notes

corrected

1000A PER - Payer Web Site situational rule updated, & added

TR3 Notes

1000B N4 – Payee City, State, ZIP Code, usage change added &

situational rule updated

2100 NM1 – Patient Name, new TR3 Notes added

2100 NM1 – Insured Name situational rule updated & TR3 Notes

updated

2110 REF – Healthcare Policy Identification, added additional

bulletin item under situational rule

GE – segment repeat count deleted in 5010A1

IEA – segment repeat count deleted in 5010A1

Sun Park August 18, 2010

Date post:	25-Jan-2021
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835 Business Impacts 005010X221A1...New Element UR: Uniform Resource Locator (URL) Usage: Required ....

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