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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 /
Element Element Name
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
Length: 1 - 30 Length: 1 - 50 Maximum length increase from 30 - 50
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N/A CUR03 Foreign Currency Information Exchange Rate
Element Deleted
N/A REF02 Receiver Identification Receiver Identification
Length: 1 - 30 Length: 1 - 50 Maximum length increase from 30 - 50
N/A REF02 Version Identification Version Identification Code
Length: 1 - 30 Length: 1 - 50 Maximum length increase from 30 - 50
Loop 1000A Payer Identification
Loop Segment /
Element Element Name
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
United States of America, including its territories, or
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 /
Element Element Name
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
Usage: Situational TR3 Usage Rule:
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
Length: 1 - 30 Length: 1 - 50 Maximum length increase from 30 - 50
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
Usage: Situational TR3 Usage Rule:
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 /
Element Element Name
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)
Usage: Situational TR3 Usage Rule:
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
Usage: Situational TR3 Usage Rule:
SITUATIONAL RULE: Required when a contact
communication number is to be transmitted. If not
required by this implementation guide, do not send.
1000A PER05 Payer Technical Contact Information Communication Number Qualifier
New Element EM:
Electronic Mail
EX: Telephone Extension
FX: Facsimile TE:
Telephone
UR: Uniform Resource Locator (URL)
Usage: Situational TR3 Usage Rule:
SITUATIONAL RULE: Required when a second
communication contact number is needed. If not
required by this implementation guide, do not send.
1000A PER06
Payer Technical Contact Information Payer Contact Communication Number
New Element Length: 1 - 256
Usage: Situational TR3 Usage Rule:
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 /
Element Element Name
4010
Valid Values
and
Descriptions
5010
Valid Values
and
Descriptions
5010A1
Valid Values
and
Descriptions
Notes
1000A PER07 Payer Technical Contact Information Communication Number Qualifier
New Element EM:
Electronic Mail
EX: Telephone Extension
FX: Facsimile UR: Uniform
Resource Locator (URL)
Usage: Situational TR3 Usage Rule:
SITUATIONAL RULE: Required when a second
communication contact number is needed. If not
required by this implementation guide, do not send.
1000A PER08
Payer Technical Contact Information Payer Contact Communication Number
New Element Length: 1 - 256
Usage: Situational TR3 Usage Rule:
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 /
Element Element Name
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 /
Element Element Name
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 /
Element Element Name
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
United States of America, including its territories, or
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
United States of America, including its territories, or
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
Usage: Situational TR3 Usage Rule:
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 /
Element Element Name
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
0B: State License Number
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 /
Element Element Name
4010
Valid Values
and
Descriptions
5010
Valid Values
and
Descriptions
5010A1
Valid Values
and
Descriptions
Notes
1000B REF02 Payee Additional Identification Additional Payee Identifier
Length: 1 - 30 Length: 1 - 50 Maximum length increase from 30 - 50
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
required by this implementation guide, do not send.
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 /
Element Element Name
4010
Valid Values
and
Descriptions
5010
Valid Values
and
Descriptions
5010A1
Valid Values
and
Descriptions
Notes
2000 TS301 Provider Summary Information Provider Identifier
Length: 1 - 30 Length: 1 - 50 Maximum length increase from 30 - 50
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 /
Element Element Name
4010
Valid Values
and
Descriptions
5010
Valid Values
and
Descriptions
5010A1
Valid Values
and
Descriptions
Notes
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Loop Segment /
Element Element Name
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 /
Element Element Name
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 /
Element Element Name
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
required by this implementation guide, do not send.
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Loop Segment /
Element Element Name
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
implementation guide, do not send.
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
34: Social Security Number
HN: Health Insurance Claim (HIC) Number
II: Standard Unique Health Identifier for each Individual in the United States
MI: Member
Identification Number
MR: Medicaid Recipient
Identification Number
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 /
Element Element Name
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
Length: 1 - 25 Length: 1 – 35 Maximum length changed from 25 – 35
2100 NM108 Insured Name Identification Code Qualifier
34: Social Security Number
HN: Health
Insurance Claim (HIC) Number
MI: Member
Identification Number
FI: Federal
Taxpayer’s
Identification Number
II: Standard
Unique Health
Identifier for each Individual in the United States
MI: Member
Identification Number
Codes Deleted Codes Added TR3 Usage notes for value ‘FI’
Not Used when NM102=1. TR3 Usage notes for value ‘II’
Use this code if mandated in a final Federal Rule.
2100 NM103
Corrected Patient/Insured Name Corrected Patient/Insured Last Name
Length: 1 - 35 Length: 1 – 60 Maximum length changed from 35 – 60
2100 NM104
Corrected Patient/Insured Name Corrected Patient/Insured First Name
Length: 1 - 25 Length: 1 – 35 Maximum length changed from 25 – 35
2100 NM103 Service Provider Name Service Provider Last Name
Length: 1 - 35 Length: 1 – 60 Maximum length changed from 35 – 60
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Loop Segment /
Element Element Name
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
Length: 1 - 25 Length: 1 – 35 Maximum length changed from 25 – 35
2100 NM103 Crossover Carrier Name Crossover Carrier Name
Length: 1 - 35 Length: 1 – 60 Maximum length changed from 35 – 60
2100 NM103 Corrected Priority Payer Name Corrected Priority Payer Name
Length: 1 - 35 Length: 1 – 60 Maximum length changed from 35 – 60
2100 NM1 Other Subscriber Name New Segment
Usage: Situational TR3 Usage Rule:
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
Usage: Situational TR3 Usage Rule:
SITUATIONAL RULE: Required when known or when
NM109 is not present. If not required by this
implementation guide, do not send.
At least one of NM103 or NM109 must be present.
2100 NM104 Other Subscriber Name Other Subscriber First Name
New Element Length: 1-35
Usage: Situational TR3 Usage Rule:
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
implementation guide, do not send.
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Loop Segment /
Element Element Name
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
New Element Length: 1-25
Usage: Situational TR3 Usage Rule:
SITUATIONAL RULE: Required when the Other
Subscriber is a person (NM102=1) and the middle
name or initial is known. If not required by this
implementation guide, do not send.
2100 NM107 Other Subscriber Name Other Subscriber Name Suffix
New Element Length: 1-10
Usage: Situational TR3 Usage Rule:
SITUATIONAL RULE: Required when the Other
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
implementation guide, do not send.
2100 NM108 Other Subscriber Name Identification Code Qualifier
New Element FI: Federal
Taxpayer’s
Identification Number
II: Standard Unique Health Identifier for each Individual in the United States
MI: Member
Identification Number
Usage: Situational TR3 Usage Rule:
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’
Use this code if mandated in a final Federal Rule.
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
implementation guide, do not send.
At least one of NM103 or NM109 must be present.
-
Page 24 of 44
Loop Segment /
Element Element Name
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
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
MOA03 MOA04 MOA05 MOA06 MOA07
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.
-
Page 25 of 44
Loop Segment /
Element Element Name
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
Identification Number
28: Employee
Identification Number
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
Identification Number
F8: Original Reference Number G1: Prior
Authorization Number
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).
-
Page 26 of 44
Loop Segment /
Element Element Name
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
1D: Medicaid Provider Number
1G: Provider UPIN Number
1H: CHAMPUS Identification Number
D3: National
Association of Boards of Pharmacy Number
G2: Provider Commercial Number
0B: State License Number
1A: Blue Cross Provider Number
1B: Blue Shield Provider Number
1C: Medicare Provider Number
1D: Medicaid Provider Number
1G: Provider UPIN Number
1H: CHAMPUS Identification Number
1J: Facility ID Number
D3: National
Association
of Boards of
Pharmacy Number
G2: Provider
Commercial Number
LU: Location Number
Codes Added
-
Page 27 of 44
Loop Segment /
Element Element Name
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.
-
Page 28 of 44
Loop Segment /
Element Element Name
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
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
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
-
Page 29 of 44
Loop Segment /
Element Element Name
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
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 -
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
-
Page 30 of 44
Loop 2110 Service Payment Information
Loop Segment /
Element Element Name
4010
Valid Values
and
Descriptions
5010
Valid Values
and
Descriptions
5010A1
Valid Values
and
Description
s
Notes
-
Page 31 of 44
Loop Segment /
Element Element Name
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
AD: American Dental Association Codes
ER: Jurisdiction Specific Procedure and Supply Codes
HC: Health Care Financing
Administration Common Procedural Coding System (HCPCS) Codes
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
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:
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 National Health
Related Item Code in 4-6 Format Codes as an
allowable code
set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
Value ‘UI’
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 U.P.C. Consumer
Package Code (1-5-5) Codes as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
Value ‘WK’
This code set is not allowed for use under HIPAA
at the time of this writing. The qualifier can only
be
used in transactions covered under HIPAA by
parties registered in the pilot project and their
trading partners.
-
Page 32 of 44
Loop Segment /
Element Element Name
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
-
Page 33 of 44
Loop Segment /
Element Element Name
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
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 (NUBC) UB82 Codes
ZZ: Mutually
AD: American Dental Association Codes
ER: Jurisdiction Specific Procedure and Supply Codes
HC: Health Care Financing
Administration Common Procedural Coding System (HCPCS) Codes
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:
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 ‘WK’
This code set is not allowed for use under HIPAA
at the time of this writing. The qualifier can only
be
used in transactions covered under HIPAA by
parties registered in the pilot project and their
trading partners.
-
Page 34 of 44
Loop Segment /
Element Element Name
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
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).
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
Authorization Number
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
Length: 1 - 30 Length: 1 - 50 Maximum length increase from 30 – 50
-
Page 35 of 44
Loop Segment /
Element Element Name
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
Length: 1 - 30 Length: 1 - 50 Maximum length increase from 30 – 50
-
Page 36 of 44
Loop Segment /
Element Element Name
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
1B: Blue Shield Provider Number
1C: Medicare Provider Number
1D: Medicaid Provider Number
1G: Provider UPIN Number
1H: CHAMPUS Identification Number
1J: Facility ID Number
HPI: Health Care
Financing Administration National Provider Identifier
SY: Social Security Number
TJ: Federal Taxpayer's Identification Number
0B: State License Number
1A: Blue Cross Provider Number
1B: Blue Shield Provider Number
1C: Medicare Provider Number
1D: Medicaid Provider Number
1G: Provider UPIN Number
1H: CHAMPUS Identification Number
1J: Facility ID Number
D3: National Council for Prescription Drug Programs Pharmacy Number
G2: Provider Commercial Number
HPI: Health Care Financing Administration National Provider Identifier
SY: Social Security Number
TJ: Federal Taxpayer's Identification Number
Codes Added
-
Page 37 of 44
Loop Segment /
Element Element Name
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.
-
Page 38 of 44
Loop Segment /
Element Element Name
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
New Element Length: 1 - 50
Usage: Required
-
Page 39 of 44
Loop Segment /
Element Element Name
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
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 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
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 Medicare or Medicaid Payment Mandate - Category 5
Maximum segment repeat changed from 12 to 9. Codes Deleted
-
Page 40 of 44
Loop Segment /
Element Element Name
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
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
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 Medicare or Medicaid Payment Mandate - Category 5
Code Deleted
Transaction Summary
Loop Segment /
Element Element Name
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
-
Page 41 of 44
Loop Segment /
Element Element Name
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
-
Page 42 of 44
Loop Segment /
Element Element Name
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
Length: 1 - 30 Length: 1 - 50 Maximum length increase from 30 - 50
-
Page 43 of 44
Interchange Trailer Changes
Loop Segment /
Element Element Name
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
-
Page 44 of 44
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