Appendix E - Data Element Glossary

Data Element Name Index

This section contains an alphabetic listing of data elements used in this implementation guide. Consult the X12N Data Element Dictionary for a complete list of all X12N Data Elements. Data element names in normal type are generic ASC X12 names. Italic type indicates a health care industry defined name.

Legend

Industry Name
Industry name definition.
800 - Transaction Set ID and Name
H=Header, D=Detail, S=Summary | Loop ID | Reference Designator | Composite ID-Position in Composite | X12 Data Element Number
 
Account Number Qualifier
Code indicating the type of account
835 - Health Care Claim Payment/Advice
H | | BPR08 | - | 569
H | | BPR14 | - | 569
 
Additional Payee Identifier
Additional unique identifier designating the payee.
835 - Health Care Claim Payment/Advice
H | 1000B | REF02 | - | 127
 
Additional Payer Identifier
Additional unique identifier designating the payer.
835 - Health Care Claim Payment/Advice
H | 1000A | REF02 | - | 127
 
Adjudicated Procedure Code
The procedure code under which a payer determined payment/benefits during the adjudication of a health care service.
835 - Health Care Claim Payment/Advice
D | 2110 | SVC01 | C003-02 | 234
 
Adjustment Amount
Adjustment amount for the associated reason code.
835 - Health Care Claim Payment/Advice
D | 2100 | RAS01 | - | 782
D | 2110 | RAS01 | - | 782
 
Adjustment Quantity
Numeric quantity associated with the related reason code for coordination of benefits.
835 - Health Care Claim Payment/Advice
D | 2100 | RAS04 | - | 380
D | 2110 | RAS04 | - | 380
 
Adjustment Reason Code
Code that indicates the reason for the adjustment.
835 - Health Care Claim Payment/Advice
D | 2100 | RAS03 | C058-01 | 1034
D | 2110 | RAS03 | C058-01 | 1034
S | | PLB03 | C042-01 | 426
S | | PLB05 | C042-01 | 426
S | | PLB07 | C042-01 | 426
S | | PLB09 | C042-01 | 426
S | | PLB11 | C042-01 | 426
S | | PLB13 | C042-01 | 426
 
Amount Qualifier Code
Code to qualify amount.
835 - Health Care Claim Payment/Advice
D | 2100 | AMT01 | - | 522
D | 2100 | AMT01 | - | 522
D | 2110 | AMT01 | - | 522
D | 2110 | AMT01 | - | 522
 
Assigned Number
Number assigned for differentiation within a transaction set.
835 - Health Care Claim Payment/Advice
D | 2000 | LX01 | - | 554
 
Average DRG Length of Stay
Average length of stay for DRGs for this provider for this type of bill summary, for this fiscal period, for this interchange transmission.
835 - Health Care Claim Payment/Advice
D | 2000 | TS210 | - | 380
 
Average DRG weight
Average DRG weight for DRGs for this provider for this type of bill summary, for this fiscal period, for this interchange transmission.
835 - Health Care Claim Payment/Advice
D | 2000 | TS216 | - | 380
 
Card Expiration Date
NEED DEFINITION.
835 - Health Care Claim Payment/Advice
H | | DTM02 | - | 373
 
Card Security Verification Code
NEED DEFINITION.
835 - Health Care Claim Payment/Advice
H | | REF02 | - | 127
 
Check or EFT Trace Number or Card Number / Card Payment Identifier
Check number or Electronic Funds Transfer (EFT) or Card Number / Card Payment Identifier - number that is unique within the sender/receiver relationship.
835 - Health Care Claim Payment/Advice
H | | TRN02 | - | 127
 
Claim Adjustment Group Code
Code identifying the general category of payment adjustment.
835 - Health Care Claim Payment/Advice
D | 2100 | RAS02 | - | 1785
D | 2110 | RAS02 | - | 1785
 
Claim Allowed Amount
NEED DEFINITION.
835 - Health Care Claim Payment/Advice
D | 2100 | AMT02 | - | 782
 
Claim Authorization Number
NEED DEFINITION.
835 - Health Care Claim Payment/Advice
D | 2100 | REF02 | - | 127
 
Claim Contact Communications Number
Complete claim contact communications number, including country or area code when applicable.
835 - Health Care Claim Payment/Advice
D | 2100 | PER04 | - | 364
D | 2100 | PER06 | - | 364
D | 2100 | PER04 | - | 364
D | 2100 | PER06 | - | 364
 
Claim Contact Name
Name of the payer's contact person associated with the claim.
835 - Health Care Claim Payment/Advice
D | 2100 | PER02 | - | 93
D | 2100 | PER02 | - | 93
 
Claim DRG Amount
Total of Prospective Payment System operating and capital amounts for this claim.
835 - Health Care Claim Payment/Advice
D | 2100 | MIA04 | - | 782
 
Claim Date
Date associated with the claim.
835 - Health Care Claim Payment/Advice
D | 2100 | DTM02 | - | 373
 
Claim Disproportionate Share Amount
Sum of operating capital disproportionate share amounts for this claim.
835 - Health Care Claim Payment/Advice
D | 2100 | MIA06 | - | 782
 
Claim ESRD Payment Amount
End Stage Renal Disease (ESRD) payment amount for the claim.
835 - Health Care Claim Payment/Advice
D | 2100 | MOA08 | - | 782
 
Claim Exchange Rate
Multiplier to convert monetary value from one currency to another.
835 - Health Care Claim Payment/Advice
D | 2100 | CLP15 | - | 280
 
Claim Frequency Code
Code specifying the frequency of the claim. This is the third position of the Uniform Billing Claim Form Bill Type.
835 - Health Care Claim Payment/Advice
D | 2100 | CLP09 | - | 1325
 
Claim HCPCS Payable Amount
Sum of payable line item amounts for HCPCs codes billed on this claim.
835 - Health Care Claim Payment/Advice
D | 2100 | MOA02 | - | 782
 
Claim Indirect Teaching Amount
Total of operating and capital indirect teaching amounts for this claim.
835 - Health Care Claim Payment/Advice
D | 2100 | MIA18 | - | 782
 
Claim MSP Pass-through Amount
Interim cost pass-though amount used to determine Medicare Secondary Payer liability.
835 - Health Care Claim Payment/Advice
D | 2100 | MIA07 | - | 782
 
Claim PPS Capital Amount
Total Prospective Payment System (PPS) capital amount payable for this claim as output by PPS PRICER.
835 - Health Care Claim Payment/Advice
D | 2100 | MIA08 | - | 782
 
Claim PPS Capital Outlier Amount
Total Prospective Payment System capital day or cost outlier payable for this claim, excluding operating outlier amount.
835 - Health Care Claim Payment/Advice
D | 2100 | MIA17 | - | 782
 
Claim Payment Amount
Net provider reimbursement amount for this claim (includes all payment to the provider).
835 - Health Care Claim Payment/Advice
D | 2100 | CLP04 | - | 782
 
Claim Status Code
Code specifying the status of a claim submitted by the provider to the payer for processing.
835 - Health Care Claim Payment/Advice
D | 2100 | CLP02 | - | 1029
 
Claim Supplemental Information Amount
Amount of supplemental information values associated with the claim.
835 - Health Care Claim Payment/Advice
D | 2100 | AMT02 | - | 782
 
Claim Supplemental Information Quantity
Numeric value of the quantity of supplemental information associated with the claim.
835 - Health Care Claim Payment/Advice
D | 2100 | QTY02 | - | 380
 
Class of Contract Code
The Class of Contract represents the terms of a contract or regulation. It includes, but is not limited to products and lines of business of the health plan.
835 - Health Care Claim Payment/Advice
D | 2100 | REF02 | - | 127
 
Clean Claim Date
Date on which all information needed for adjudication is received by the payer.
835 - Health Care Claim Payment/Advice
D | 2100 | DTM02 | - | 373
 
Code List Qualifier Code
Code identifying a specific industry code list.
835 - Health Care Claim Payment/Advice
D | 2100 | CLP11 | C022-01 | 1270
D | 2100 | RAS03 | C058-02 | 1270
D | 2100 | LQ01 | - | 1270
D | 2110 | RAS03 | C058-02 | 1270
D | 2110 | LQ01 | - | 1270
 
Communication Number
Complete communications number including country or area code when applicable
835 - Health Care Claim Payment/Advice
H | 1000A | PER04 | - | 364
H | 1000B | RDM03 | - | 364
 
Communication Number Extension
Extension for the previous communications number.
835 - Health Care Claim Payment/Advice
D | 2100 | PER08 | - | 364
D | 2100 | PER08 | - | 364
 
Communication Number Qualifier
Code identifying the type of communication number.
835 - Health Care Claim Payment/Advice
H | 1000A | PER03 | - | 365
H | 1000A | PER05 | - | 365
H | 1000A | PER07 | - | 365
H | 1000A | PER03 | - | 365
H | 1000A | PER05 | - | 365
H | 1000A | PER07 | - | 365
H | 1000A | PER03 | - | 365
D | 2100 | PER03 | - | 365
D | 2100 | PER05 | - | 365
D | 2100 | PER07 | - | 365
D | 2100 | PER03 | - | 365
D | 2100 | PER05 | - | 365
D | 2100 | PER07 | - | 365
D | 2100 | PER03 | - | 365
 
Contact Function Code
Code identifying the major duty or responsibility of the person or group named.
835 - Health Care Claim Payment/Advice
H | 1000A | PER01 | - | 366
H | 1000A | PER01 | - | 366
H | 1000A | PER01 | - | 366
D | 2100 | PER01 | - | 366
D | 2100 | PER01 | - | 366
D | 2100 | PER01 | - | 366
 
Contracting Entity Payer Identifier
This is the identifier of the entity that assigned the Class of Contract Code.
835 - Health Care Claim Payment/Advice
D | 2100 | REF04 | C040-02 | 127
 
Corrected Accident Date
Corrected date of the accident related to charges or to the patient's current condition, diagnosis, or treatment referenced in the transaction.
835 - Health Care Claim Payment/Advice
D | 2100 | DTM02 | - | 373
 
Corrected Onset of Current Symptoms or Illness Date
Corrected date of onset of indicated patient condition.
835 - Health Care Claim Payment/Advice
D | 2100 | DTM02 | - | 373
 
Corrected Patient or Subscriber First Name
Corrected first name of the patient or subscriber.
835 - Health Care Claim Payment/Advice
D | 2100 | NM104 | - | 1036
 
Corrected Patient or Subscriber Identification Number
NEED DEFINITION.
835 - Health Care Claim Payment/Advice
D | 2100 | NM109 | - | 67
 
Corrected Patient or Subscriber Last Name
Corrected last name of the patient or subscriber.
835 - Health Care Claim Payment/Advice
D | 2100 | NM103 | - | 1035
 
Corrected Patient or Subscriber Middle Name
Corrected middle name of the patient or insured.
835 - Health Care Claim Payment/Advice
D | 2100 | NM105 | - | 1037
 
Corrected Patient or Subscriber Name Suffix
Corrected suffix for the name of the patient or subscriber.
835 - Health Care Claim Payment/Advice
D | 2100 | NM107 | - | 1039
 
Corrected Priority Payer Identification Number
Corrected identification number of the patient/subscriber.
835 - Health Care Claim Payment/Advice
D | 2105 | N104 | - | 67
 
Corrected Priority Payer Name
Name of the corrected priority payer.
835 - Health Care Claim Payment/Advice
D | 2105 | N102 | - | 93
 
Cost Report Day Count
The number of days that may be claimed as Medicare patient days on a cost report.
835 - Health Care Claim Payment/Advice
D | 2100 | MIA15 | - | 380
 
Covered Days or Visits Count
Number of days or visits covered by the primary payer or days/visits that would have been covered had Medicare been primary.
835 - Health Care Claim Payment/Advice
D | 2100 | MIA01 | - | 380
 
Credit or Debit Flag Code
Code indicating whether amount is a credit or debit
835 - Health Care Claim Payment/Advice
H | | BPR03 | - | 478
 
Crossover Carrier Identifier
Number assigned by the payer to identify the coordination of benefits carrier.
835 - Health Care Claim Payment/Advice
D | 2100 | NM109 | - | 67
 
Crossover Carrier Name
Name of the crossover carrier associated with the claim.
835 - Health Care Claim Payment/Advice
D | 2100 | NM103 | - | 1035
 
Currency Code
Code for country in whose currency the charges are specified.
835 - Health Care Claim Payment/Advice
H | | CUR02 | - | 100
 
Date
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year.
835 - Health Care Claim Payment/Advice
D | 2100 | DTM02 | - | 373
D | 2100 | DTM02 | - | 373
 
Date Time Qualifier
Code specifying the type of date or time or both date and time.
835 - Health Care Claim Payment/Advice
H | | DTM01 | - | 374
H | | DTM01 | - | 374
D | 2100 | DTM01 | - | 374
D | 2100 | DTM01 | - | 374
D | 2100 | DTM01 | - | 374
D | 2100 | DTM01 | - | 374
D | 2100 | DTM01 | - | 374
D | 2100 | DTM01 | - | 374
D | 2110 | DTM01 | - | 374
 
Depository Financial Institution (DFI) Identification Number Qualifier
Code identifying the type of identification number of Depository Financial Institution (DFI).
835 - Health Care Claim Payment/Advice
H | | BPR06 | - | 506
H | | BPR12 | - | 506
 
Diagnosis Related Group (DRG) Weight
Diagnosis related group weight for this claim
835 - Health Care Claim Payment/Advice
D | 2100 | CLP12 | - | 380
 
Discharge Fraction
The number of days billed are divided by the Average Length of Stay.
835 - Health Care Claim Payment/Advice
D | 2100 | CLP13 | - | 954
 
Entity Identifier Code
Code identifying an organizational entity, a physical location, property or an individual.
835 - Health Care Claim Payment/Advice
H | | CUR01 | - | 98
H | 1000A | N101 | - | 98
H | 1000B | N101 | - | 98
D | 2100 | NM101 | - | 98
D | 2100 | NM101 | - | 98
D | 2100 | NM101 | - | 98
D | 2100 | NM101 | - | 98
D | 2100 | NM101 | - | 98
D | 2105 | N101 | - | 98
D | 2105 | NM101 | - | 98
 
Entity Type Qualifier
Code qualifying the type of entity.
835 - Health Care Claim Payment/Advice
D | 2100 | NM102 | - | 1065
D | 2100 | NM102 | - | 1065
D | 2100 | NM102 | - | 1065
D | 2100 | NM102 | - | 1065
D | 2100 | NM102 | - | 1065
D | 2105 | NM102 | - | 1065
 
Facility Type Code
Code identifying the type of facility where services were performed; the first and second positions of the Uniform Bill Type code or the Place of Service code from the Electronic Media Claims National Standard Format.
835 - Health Care Claim Payment/Advice
D | 2000 | TS302 | - | 1331
D | 2100 | CLP08 | - | 1331
 
Fiscal Period Date
Last day of provider's fiscal year through date of the bill.
835 - Health Care Claim Payment/Advice
D | 2000 | TS303 | - | 373
S | | PLB02 | - | 373
 
Healthcare Policy Identification
A Health Plan assigned identification for the Health Plan's documented provision for applying a specific benefit to medical claims, as found in the Health Plan's publication.
835 - Health Care Claim Payment/Advice
D | 2110 | REF02 | - | 127
 
Identification Code Qualifier
Code designating the system/method of code structure used for Identification Code (67).
835 - Health Care Claim Payment/Advice
H | 1000A | N103 | - | 66
H | 1000B | N103 | - | 66
D | 2100 | NM108 | - | 66
D | 2100 | NM108 | - | 66
D | 2100 | NM108 | - | 66
D | 2100 | NM108 | - | 66
D | 2100 | NM108 | - | 66
D | 2105 | N103 | - | 66
D | 2105 | NM108 | - | 66
 
Implementation Guide Version Name
Name of the referenced implementation guide version.
835 - Health Care Claim Payment/Advice
H | | ST03 | - | 1705
 
Industry Code
Code indicating a code from a specific industry code list.
835 - Health Care Claim Payment/Advice
D | 2100 | CLP11 | C022-02 | 1271
 
Jurisdiction Name
Name of the jurisdiction receiving the report.
835 - Health Care Claim Payment/Advice
D | 2100 | PER02 | - | 93
 
Jurisdiction/Payer Website URL
Link to the jurisdiction/payer's website.
835 - Health Care Claim Payment/Advice
D | 2100 | PER04 | - | 364
 
Lifetime Psychiatric Days Count
Number of lifetime psychiatric days used for this claim.
835 - Health Care Claim Payment/Advice
D | 2100 | MIA03 | - | 380
 
Line Item Charge Amount
Charges related to this service.
835 - Health Care Claim Payment/Advice
D | 2110 | SVC02 | - | 782
 
Line Item Control Number
Identifier assigned by the submitter/provider to this line item.
835 - Health Care Claim Payment/Advice
D | 2110 | REF02 | - | 127
 
Line Item Provider Payment Amount
The actual amount paid to the provider for this service line.
835 - Health Care Claim Payment/Advice
D | 2110 | SVC03 | - | 782
 
Method of Claim Submission
NEED DEFINITION.
835 - Health Care Claim Payment/Advice
D | 2100 | REF04 | C040-02 | 127
 
Name
Free-form name.
835 - Health Care Claim Payment/Advice
H | 1000B | RDM02 | - | 93
 
National Uniform Billing Committee Revenue Code
Code values from the National Uniform Billing Committee Revenue Codes.
835 - Health Care Claim Payment/Advice
D | 2110 | SVC04 | - | 234
 
Nonpayable Professional Component Amount
Professional fees billed but not payable by payer.
835 - Health Care Claim Payment/Advice
D | 2100 | MIA19 | - | 782
D | 2100 | MOA09 | - | 782
 
Old Capital Amount
The amount for old capital for this claim.
835 - Health Care Claim Payment/Advice
D | 2100 | MIA12 | - | 782
 
Oral Cavity Area/Tooth Code
Identifies the tooth, quadrant, sextant or arch on which services were performed or will be performed.
835 - Health Care Claim Payment/Advice
D | 2110 | TOO02 | - | 1271
 
Oral Cavity Area/Tooth Qualifier Code
NEED DEFINITION.
835 - Health Care Claim Payment/Advice
D | 2110 | TOO01 | - | 1270
 
Original Claim Type
NEED DEFINITION.
835 - Health Care Claim Payment/Advice
D | 2100 | REF02 | - | 127
 
Original Payer Claim Control Number
NEED DEFINITION.
835 - Health Care Claim Payment/Advice
D | 2100 | REF02 | - | 127
 
Original Units of Service Count
Original units of service that were submitted by the provider (in days or units).
835 - Health Care Claim Payment/Advice
D | 2110 | SVC07 | - | 380
 
Originating Company Supplemental Code
Number identifying a further subdivision within the entity originating the transaction.
835 - Health Care Claim Payment/Advice
H | | BPR11 | - | 510
H | | TRN04 | - | 127
 
Other Claim Related Identifier
Code identifying other claim related reference numbers.
835 - Health Care Claim Payment/Advice
D | 2100 | REF02 | - | 127
 
Other Subscriber First Name
The first name of the Other Subscriber.
835 - Health Care Claim Payment/Advice
D | 2105 | NM104 | - | 1036
 
Other Subscriber Identifier
An identification number, assigned by the third party payer, to identify the Other Subscriber.
835 - Health Care Claim Payment/Advice
D | 2105 | NM109 | - | 67
 
Other Subscriber Last Name
The last name of the Other Subscriber.
835 - Health Care Claim Payment/Advice
D | 2105 | NM103 | - | 1035
 
Other Subscriber Middle Name or Initial
This is the middle name or initial of the Other Subscriber.
835 - Health Care Claim Payment/Advice
D | 2105 | NM105 | - | 1037
 
Other Subscriber Name Suffix
The suffix to the name of the Other Subscriber.
835 - Health Care Claim Payment/Advice
D | 2105 | NM107 | - | 1039
 
PPS Operating Outlier Amount
Prospective Payment System addition to payment rate as excessive costs incurred.
835 - Health Care Claim Payment/Advice
D | 2100 | MIA02 | - | 782
 
PPS-Capital DSH DRG Amount
PPS-capital disproportionate share amount for this claim as output by PPS-PRICER.
835 - Health Care Claim Payment/Advice
D | 2100 | MIA11 | - | 782
 
PPS-Capital Exception Amount
A per discharge payment exception paid to the hospital. It is a flat-rate add-on to the PPS payment.
835 - Health Care Claim Payment/Advice
D | 2100 | MIA24 | - | 782
 
PPS-Capital FSP DRG Amount
PPS-capital federal portion for this claim as output by PPS-PRICER.
835 - Health Care Claim Payment/Advice
D | 2100 | MIA09 | - | 782
 
PPS-Capital HSP DRG Amount
Hospital-Specific portion for PPS-capital for this claim as output by PPS-PRICER.
835 - Health Care Claim Payment/Advice
D | 2100 | MIA10 | - | 782
 
PPS-Capital IME amount
PPS-capital indirect medical expenses for this claim as output by PPS-PRICER.
835 - Health Care Claim Payment/Advice
D | 2100 | MIA13 | - | 782
 
PPS-Operating Federal Specific DRG Amount
Sum of federal operating portion of the DRG amount this claim as output by PPS-PRICER.
835 - Health Care Claim Payment/Advice
D | 2100 | MIA16 | - | 782
 
PPS-Operating Hospital Specific DRG Amount
Sum of hospital specific operating portion of DRG amount for this claim as output by PPS-PRICER.
835 - Health Care Claim Payment/Advice
D | 2100 | MIA14 | - | 782
 
Patient First Name
The first name of the individual to whom the services were provided.
835 - Health Care Claim Payment/Advice
D | 2100 | NM104 | - | 1036
 
Patient Identifier
Patient identification code
835 - Health Care Claim Payment/Advice
D | 2100 | NM109 | - | 67
 
Patient Last Name
The last name of the individual to whom the services were provided.
835 - Health Care Claim Payment/Advice
D | 2100 | NM103 | - | 1035
 
Patient Middle Name or Initial
The middle name or initial of the individual to whom the services were provided.
835 - Health Care Claim Payment/Advice
D | 2100 | NM105 | - | 1037
 
Patient Name Suffix
Suffix to the name of the individual to whom the services were provided.
835 - Health Care Claim Payment/Advice
D | 2100 | NM107 | - | 1039
 
Patient Responsibility Amount
The amount determined to be the patient's responsibility for payment.
835 - Health Care Claim Payment/Advice
D | 2100 | CLP05 | - | 782
 
Payee Address Line
Payee's claim mailing address for this particular payee organization identification and claim office.
835 - Health Care Claim Payment/Advice
H | 1000B | N301 | - | 166
H | 1000B | N302 | - | 166
 
Payee City Name
Name of the city of the payee's claim mailing address for this particular payee ID and claim office.
835 - Health Care Claim Payment/Advice
H | 1000B | N401 | - | 19
 
Payee Country Code
Country code of the payee's claim mailing address for this particular payee organization identification and claim office.
835 - Health Care Claim Payment/Advice
H | 1000B | N404 | - | 26
 
Payee Country Subdivision Code
Country subdivision code of the payee's claim mailing address for this particular payee organization identification and claim office.
835 - Health Care Claim Payment/Advice
H | 1000B | N407 | - | 1715
 
Payee Identification Code
Code identifying the entity to whom payment will be directed.
835 - Health Care Claim Payment/Advice
H | 1000B | N104 | - | 67
 
Payee Name
Name identifying the payee organization to whom payment is directed.
835 - Health Care Claim Payment/Advice
H | 1000B | N102 | - | 93
 
Payee Postal Zone or ZIP Code
Zip code of the payee's claim mailing address for this particular payee organization identification and claim office.
835 - Health Care Claim Payment/Advice
H | 1000B | N403 | - | 116
 
Payee State Code
State postal code of the payee's claim mailing address for this particular payee organization identification and claim office.
835 - Health Care Claim Payment/Advice
H | 1000B | N402 | - | 156
 
Payee Tax Identification Number
Tax Identification Number of the entity to whom payment will be directed.
835 - Health Care Claim Payment/Advice
H | 1000B | REF02 | - | 127
 
Payer Address Line
Address line of the Payer's claim mailing address for this particular payer organization identification and claim office.
835 - Health Care Claim Payment/Advice
H | 1000A | N301 | - | 166
H | 1000A | N302 | - | 166
 
Payer City Name
The City Name of the Payer's claim mailing address for this particular payer ID and claim office.
835 - Health Care Claim Payment/Advice
H | 1000A | N401 | - | 19
 
Payer Claim Control Number
A number assigned by the payer to identify a claim. The number is usually referred to as an Internal Control Number (ICN), Claim Control Number (CCN) or a Document Control Number (DCN).
835 - Health Care Claim Payment/Advice
D | 2100 | CLP07 | - | 127
 
Payer Contact Communication Number
Complete payer contact communications number, including country or area code when applicable.
835 - Health Care Claim Payment/Advice
H | 1000A | PER04 | - | 364
H | 1000A | PER06 | - | 364
H | 1000A | PER08 | - | 364
H | 1000A | PER04 | - | 364
H | 1000A | PER08 | - | 364
 
Payer Contact Name
Name identifying the payer organization's contact person.
835 - Health Care Claim Payment/Advice
H | 1000A | PER02 | - | 93
 
Payer Country
The country code for the payer when the payer's country is not the United States of America.
835 - Health Care Claim Payment/Advice
H | 1000A | N404 | - | 26
 
Payer Country Subdivision
The state, province or other subdivision identification of the payer's address when the payer's country is not the United States of America, including its territories, or Canada.
835 - Health Care Claim Payment/Advice
H | 1000A | N407 | - | 1715
 
Payer Identifier
Number identifying the payer organization.
835 - Health Care Claim Payment/Advice
H | | BPR10 | - | 509
H | | TRN03 | - | 509
H | 1000A | N104 | - | 67
 
Payer Name
Name identifying the payer organization.
835 - Health Care Claim Payment/Advice
H | 1000A | N102 | - | 93
 
Payer Postal Zone or ZIP Code
The ZIP Code of the Payer's claim mailing address for this particular payer organization identification and claim office.
835 - Health Care Claim Payment/Advice
H | 1000A | N403 | - | 116
 
Payer State Code
State Postal Code of the Payer's claim mailing address for this particular payer organization identification and claim office.
835 - Health Care Claim Payment/Advice
H | 1000A | N402 | - | 156
 
Payer Technical Contact Communication Number
Complete payer technical contact communications number, including country or area code when applicable.
835 - Health Care Claim Payment/Advice
H | 1000A | PER06 | - | 364
 
Payer Technical Contact Name
Name identifying the payer organization's technical contact person.
835 - Health Care Claim Payment/Advice
H | 1000A | PER02 | - | 93
 
Payment Determination Methodology
The methodology used by the payer to adjudicate and derive the allowed amount for the claim.
835 - Health Care Claim Payment/Advice
D | 2100 | REF02 | - | 127
 
Payment Effective Date
The effective date of the payment.
835 - Health Care Claim Payment/Advice
H | | BPR16 | - | 373
 
Payment Format Code
Type of format chosen to send payment
835 - Health Care Claim Payment/Advice
H | | BPR05 | - | 812
 
Payment Method Code
Code identifying the method for the movement of payment instructions.
835 - Health Care Claim Payment/Advice
H | | BPR04 | - | 591
 
Procedure Code
Code identifying the procedure, product or service.
835 - Health Care Claim Payment/Advice
D | 2110 | SVC06 | C003-02 | 234
 
Procedure Code Description
Description clarifying the Product/Service Procedure Code and related data elements.
835 - Health Care Claim Payment/Advice
D | 2110 | SVC06 | C003-07 | 352
 
Procedure Modifier
This identifies special circumstances related to the performance of the service.
835 - Health Care Claim Payment/Advice
D | 2110 | SVC01 | C003-03 | 1339
D | 2110 | SVC01 | C003-04 | 1339
D | 2110 | SVC01 | C003-05 | 1339
D | 2110 | SVC01 | C003-06 | 1339
D | 2110 | SVC01 | C003-09 | 1339
D | 2110 | SVC01 | C003-10 | 1339
D | 2110 | SVC01 | C003-11 | 1339
D | 2110 | SVC01 | C003-12 | 1339
D | 2110 | SVC06 | C003-03 | 1339
D | 2110 | SVC06 | C003-04 | 1339
D | 2110 | SVC06 | C003-05 | 1339
D | 2110 | SVC06 | C003-06 | 1339
D | 2110 | SVC06 | C003-09 | 1339
D | 2110 | SVC06 | C003-10 | 1339
D | 2110 | SVC06 | C003-11 | 1339
D | 2110 | SVC06 | C003-12 | 1339
 
Product or Service ID Qualifier
Code identifying the type/source of the descriptive number used in Product/Service ID (234).
835 - Health Care Claim Payment/Advice
D | 2110 | SVC01 | C003-01 | 235
D | 2110 | SVC06 | C003-01 | 235
 
Production Date
End date for the adjudication production cycle for the claims in the transmission.
835 - Health Care Claim Payment/Advice
H | | DTM02 | - | 373
 
Provider Adjustment Amount
Provider adjustment amount. The adjustment amount is to the total provider payment and is not related to a specific claim or service.
835 - Health Care Claim Payment/Advice
S | | PLB04 | - | 782
S | | PLB06 | - | 782
S | | PLB08 | - | 782
S | | PLB10 | - | 782
S | | PLB12 | - | 782
S | | PLB14 | - | 782
 
Provider Adjustment Identifier
Unique identifying number for the provider adjustment.
835 - Health Care Claim Payment/Advice
S | | PLB03 | C042-02 | 127
S | | PLB05 | C042-02 | 127
S | | PLB07 | C042-02 | 127
S | | PLB09 | C042-02 | 127
S | | PLB11 | C042-02 | 127
S | | PLB13 | C042-02 | 127
 
Provider Identifier
Number assigned by the payer, regulatory authority, or other authorized body or agency to identify the provider.
835 - Health Care Claim Payment/Advice
D | 2000 | TS301 | - | 127
S | | PLB01 | - | 127
 
Provider's Assigned Claim Identifier
The identifier generated by the provider for the purposes of reassociation to their claim accounts receivable.
835 - Health Care Claim Payment/Advice
D | 2100 | CLP01 | - | 1028
 
Quantity Qualifier
Code specifying the type of quantity.
835 - Health Care Claim Payment/Advice
D | 2100 | QTY01 | - | 673
D | 2110 | QTY01 | - | 673
 
Receiver Identifier
Number identifying the organization receiving the payment.
835 - Health Care Claim Payment/Advice
H | | REF02 | - | 127
 
Receiver or Provider Account Number
The receiver's/provider's Bank Account Number into which payment has been or will be deposited according to the previously identified receiving depository financial institution.
835 - Health Care Claim Payment/Advice
H | | BPR15 | - | 508
 
Receiver or Provider Bank ID Number
The American Banking Association Identification Number used to identify the receiving depository financial institution or provider's bank within the Federal Reserve System when an EFT is being sent.
835 - Health Care Claim Payment/Advice
H | | BPR13 | - | 507
 
Reference Identification Qualifier
Code qualifying the reference identification.
835 - Health Care Claim Payment/Advice
H | | REF01 | - | 128
H | | REF01 | - | 128
H | 1000A | REF01 | - | 128
H | 1000A | REF01 | - | 128
H | 1000B | REF01 | - | 128
H | 1000B | REF01 | - | 128
D | 2100 | REF01 | - | 128
D | 2100 | REF01 | - | 128
D | 2100 | REF01 | - | 128
D | 2100 | REF04 | C040-01 | 128
D | 2100 | REF01 | - | 128
D | 2100 | REF01 | - | 128
D | 2100 | REF01 | - | 128
D | 2100 | REF04 | C040-01 | 128
D | 2100 | REF01 | - | 128
D | 2110 | REF01 | - | 128
D | 2110 | REF01 | - | 128
D | 2110 | REF01 | - | 128
D | 2110 | REF01 | - | 128
D | 2110 | REF01 | - | 128
D | 2110 | REF01 | - | 128
 
Reimbursement Rate
Rate used when payment is based upon a percentage of applicable charges.
835 - Health Care Claim Payment/Advice
D | 2100 | MOA01 | - | 954
 
Remark Code
Code indicating a code from a specific industry code list, such as the Health Care Claim Status Code list.
835 - Health Care Claim Payment/Advice
D | 2100 | RAS03 | C058-03 | 1271
D | 2100 | RAS03 | C058-04 | 1271
D | 2100 | RAS03 | C058-05 | 1271
D | 2100 | RAS03 | C058-06 | 1271
D | 2100 | RAS03 | C058-07 | 1271
D | 2100 | LQ02 | - | 1271
D | 2110 | RAS03 | C058-03 | 1271
D | 2110 | RAS03 | C058-04 | 1271
D | 2110 | RAS03 | C058-05 | 1271
D | 2110 | RAS03 | C058-06 | 1271
D | 2110 | RAS03 | C058-07 | 1271
D | 2110 | LQ02 | - | 1271
 
Rendering Provider Identifier
The identifier assigned by the Payer to the provider who performed the service.
835 - Health Care Claim Payment/Advice
D | 2100 | NM109 | - | 67
D | 2110 | REF02 | - | 127
 
Rendering Provider Secondary Identifier
Additional identifier for the provider providing care to the patient.
835 - Health Care Claim Payment/Advice
D | 2100 | REF02 | - | 127
 
Report Transmission Code
Code defining timing, transmission method or format by which reports are to be sent.
835 - Health Care Claim Payment/Advice
H | 1000B | RDM01 | - | 756
 
Sender Bank Account Number
The sender's bank account number at the Originating Depository Financial Institution.
835 - Health Care Claim Payment/Advice
H | | BPR09 | - | 508
 
Sender DFI Identifier
The Depository Financial Institution (DFI) identification number of the originator of the transaction.
835 - Health Care Claim Payment/Advice
H | | BPR07 | - | 507
 
Service Allowed Amount
NEED DEFINITION.
835 - Health Care Claim Payment/Advice
D | 2110 | AMT02 | - | 782
 
Service Date
Date of service, such as the start date of the service, the end date of the service, or the single day date of the service.
835 - Health Care Claim Payment/Advice
D | 2110 | DTM02 | - | 373
 
Service Identifier
This is the service specific reference identifier used in the process of adjudicating a service line.
835 - Health Care Claim Payment/Advice
D | 2110 | REF02 | - | 127
 
Service Line Authorization Number
NEED DEFINITION.
835 - Health Care Claim Payment/Advice
D | 2110 | REF02 | - | 127
 
Service Provider First Name
First name of the provider to whom the patient has been or will be referred for service or the provider that performed the service.
835 - Health Care Claim Payment/Advice
D | 2100 | NM104 | - | 1036
 
Service Provider Last or Organization Name
Last name or organization name of the provider to whom the patient has been or will be referred for service or the provider that performed the service or where the service was performed.
835 - Health Care Claim Payment/Advice
D | 2100 | NM103 | - | 1035
 
Service Provider Middle Name
Middle name or middle initial of the provider to whom the patient has been or will be referred for service or the provider that performed the service.
835 - Health Care Claim Payment/Advice
D | 2100 | NM105 | - | 1037
 
Service Provider Name Suffix
Suffix to the name of the provider to whom the patient has been or will be referred for service or the provider that performed the service.
835 - Health Care Claim Payment/Advice
D | 2100 | NM107 | - | 1039
 
Service Reference Identifier
This is the service specific reference identifier used in the process of adjudicating a service line.
835 - Health Care Claim Payment/Advice
D | 2110 | REF02 | - | 127
 
Service Supplemental Amount
Additional amount or charge associated with the service.
835 - Health Care Claim Payment/Advice
D | 2110 | AMT02 | - | 782
 
Service Supplemental Quantity Count
Quantity of additional items associated with service.
835 - Health Care Claim Payment/Advice
D | 2110 | QTY02 | - | 380
 
Source of Payment Typology Code
A code identifying payer types in the most granular way.
835 - Health Care Claim Payment/Advice
D | 2100 | CLP16 | - | 1732
 
Subscriber First Name
The first name of the insured individual or subscriber to the coverage.
835 - Health Care Claim Payment/Advice
D | 2100 | NM104 | - | 1036
 
Subscriber Identifier
Insured's or subscriber's unique identification number assigned by a payer.
835 - Health Care Claim Payment/Advice
D | 2100 | NM109 | - | 67
 
Subscriber Last Name
The surname of the insured individual or subscriber to the coverage.
835 - Health Care Claim Payment/Advice
D | 2100 | NM103 | - | 1035
 
Subscriber Middle Name or Initial
The middle name or initial of the subscriber to the indicated coverage or policy.
835 - Health Care Claim Payment/Advice
D | 2100 | NM105 | - | 1037
 
Subscriber Name Suffix
Suffix of the insured individual or subscriber to the coverage.
835 - Health Care Claim Payment/Advice
D | 2100 | NM107 | - | 1039
 
Tooth Surface Code
The surface(s) of the tooth on which services were performed or will be performed.
835 - Health Care Claim Payment/Advice
D | 2110 | TOO03 | C005-01 | 1369
D | 2110 | TOO03 | C005-02 | 1369
D | 2110 | TOO03 | C005-03 | 1369
D | 2110 | TOO03 | C005-04 | 1369
D | 2110 | TOO03 | C005-05 | 1369
 
Total Actual Provider Payment Amount
The actual payment to the provider for this batch, transaction, or summary.
835 - Health Care Claim Payment/Advice
H | | BPR02 | - | 782
 
Total Capital Amount
Sum of claim Prospective Payment System capital amount fields for this provider for this type of bill summary, for this fiscal period.
835 - Health Care Claim Payment/Advice
D | 2000 | TS205 | - | 782
 
Total Claim Charge Amount
The sum of all charges included within this claim.
835 - Health Care Claim Payment/Advice
D | 2000 | TS305 | - | 782
D | 2100 | CLP03 | - | 782
 
Total Claim Count
Total number of claims in this transaction.
835 - Health Care Claim Payment/Advice
D | 2000 | TS304 | - | 380
 
Total Cost Outlier Amount
Sum of outlier amount fields from each claim for this provider, for this type of bill summary, for this fiscal period.
835 - Health Care Claim Payment/Advice
D | 2000 | TS209 | - | 782
 
Total Cost Report Day Count
Sum of cost report days fields for this provider, for this type of bill summary, for this fiscal period.
835 - Health Care Claim Payment/Advice
D | 2000 | TS212 | - | 380
 
Total Covered Day Count
Sum of covered days fields for this provider, for this type of bill summary, for this fiscal period.
835 - Health Care Claim Payment/Advice
D | 2000 | TS213 | - | 380
 
Total DRG Amount
Total of claim level DRG amount fields for this provider, for this type of bill summary, for this fiscal period.
835 - Health Care Claim Payment/Advice
D | 2000 | TS201 | - | 782
 
Total Day Outlier Amount
Sum of outlier amount and claim Prospective Payment System capital outlier amount for this provider, for this type of bill summary, for this fiscal period.
835 - Health Care Claim Payment/Advice
D | 2000 | TS208 | - | 782
 
Total Discharge Count
Sum of discharges for this provider for this type of bill summary, for this fiscal period.
835 - Health Care Claim Payment/Advice
D | 2000 | TS211 | - | 380
 
Total Disproportionate Share Amount
Sum of disproportionate share amount fields for this provider, for this type of bill summary, for this fiscal period.
835 - Health Care Claim Payment/Advice
D | 2000 | TS204 | - | 782
 
Total Federal Specific Amount
Total of federal-specific DRG amount fields for this provider, for this fiscal period.
835 - Health Care Claim Payment/Advice
D | 2000 | TS202 | - | 782
 
Total HCPCS Payable Amount
Sum of claim HCPCS payable amount fields for this provider, for this type of bill summary, for this fiscal period.
835 - Health Care Claim Payment/Advice
D | 2000 | TS318 | - | 782
 
Total HCPCS Reported Charge Amount
Sum of reported charge fields for the line items billed by this provider, for this type of bill summary, for this fiscal period.
835 - Health Care Claim Payment/Advice
D | 2000 | TS317 | - | 782
 
Total Hospital Specific Amount
Total hospital-specific DRG amount fields for this provider, for this type of bill summary, for this fiscal period.
835 - Health Care Claim Payment/Advice
D | 2000 | TS203 | - | 782
 
Total Indirect Medical Education Amount
Total of indirect teaching amount fields for this provider, for this type of bill summary, for this fiscal period.
835 - Health Care Claim Payment/Advice
D | 2000 | TS206 | - | 782
 
Total MSP Pass-Through Amount
Sum of claim Medicare Secondary Payer pass-through amount fields for this provider for this type of bill summary for this fiscal period for this transmission.
835 - Health Care Claim Payment/Advice
D | 2000 | TS215 | - | 782
 
Total MSP Patient Liability Met Amount
Sum of Medicare secondary payer patient liability met by patients for Medicare secondary payer for this provider, for this type of bill summary, for this fiscal period.
835 - Health Care Claim Payment/Advice
D | 2000 | TS321 | - | 782
 
Total MSP Payer Amount
Sum of Medicare secondary payer(s) amounts for this provider, for this type of bill summary for this fiscal period.
835 - Health Care Claim Payment/Advice
D | 2000 | TS313 | - | 782
 
Total Non-Lab Charge Amount
Total covered charges minus sum of amounts for revenue codes 300-319.
835 - Health Care Claim Payment/Advice
D | 2000 | TS315 | - | 782
 
Total Noncovered Day Count
Sum of non-covered days fields for this provider, for this type of bill summary, for this fiscal period.
835 - Health Care Claim Payment/Advice
D | 2000 | TS214 | - | 380
 
Total Outlier Day Count
Sum of outlier days for this provider, for this type of bill summary, for this fiscal period.
835 - Health Care Claim Payment/Advice
D | 2000 | TS207 | - | 380
 
Total PIP Adjustment Amount
Total value of Period Interim Payment adjustment for this provider, for this type of bill summary, for this fiscal period.
835 - Health Care Claim Payment/Advice
D | 2000 | TS324 | - | 782
 
Total PIP Claim Count
Total number of Periodic Interim Payment claims for this provider, for this type of bill summary, for this fiscal period.
835 - Health Care Claim Payment/Advice
D | 2000 | TS323 | - | 380
 
Total PPS Capital FSP DRG Amount
Sum of Prospective Payment System-capital federal specific DRG amount fields for this provider, for this type of bill summary, for this fiscal period.
835 - Health Care Claim Payment/Advice
D | 2000 | TS217 | - | 782
 
Total PPS Capital HSP DRG Amount
Sum of Prospective Payment System-capital hospital specific DRG amount fields for this provider, for this type of bill summary, for this fiscal period.
835 - Health Care Claim Payment/Advice
D | 2000 | TS218 | - | 782
 
Total PPS DSH DRG Amount
Sum of Prospective Payment System disproportionate share of DRG amount fields for this provider, for this type of bill summary, for this fiscal period.
835 - Health Care Claim Payment/Advice
D | 2000 | TS219 | - | 782
 
Total Patient Reimbursement Amount
Total of patient refund amount fields for this provider for this type of bill summary, for this fiscal period.
835 - Health Care Claim Payment/Advice
D | 2000 | TS322 | - | 782
 
Total Professional Component Amount
Sum of professional component fields for this provider, for this type of bill summary, for this fiscal period.
835 - Health Care Claim Payment/Advice
D | 2000 | TS320 | - | 782
 
Trace Type Code
Code identifying the type of re-association which needs to be performed.
835 - Health Care Claim Payment/Advice
H | | TRN01 | - | 481
 
Transaction Creator Identifier
NEED DEFINITION.
835 - Health Care Claim Payment/Advice
H | 1000A | REF02 | - | 127
 
Transaction Handling Code
This code designates whether and how the money and remittance information will be processed.
835 - Health Care Claim Payment/Advice
H | | BPR01 | - | 305
 
Transaction Segment Count
A tally of all segments between the ST and the SE segments including the ST and SE segments.
835 - Health Care Claim Payment/Advice
S | | SE01 | - | 96
 
Transaction Set Control Number
The unique identification number within a transaction set.
835 - Health Care Claim Payment/Advice
H | | ST02 | - | 329
S | | SE02 | - | 329
 
Transaction Set Identifier Code
Code uniquely identifying a Transaction Set.
835 - Health Care Claim Payment/Advice
H | | ST01 | - | 143
 
Units of Service Paid Count
Number of the paid units of service.
835 - Health Care Claim Payment/Advice
D | 2110 | SVC05 | - | 380