Health Care Claim Payment Advice 835 Payer Sheet

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Companion Guide – 835 Remittance Advice TransactionHealth Care Claim Payment Advice835Payer SheetJanuary 2011

Companion Guide – 835 Remittance Advice TransactionTable of ContentsSection 1: Revision History . 2-3Section 2: Health Care Claim Payment Advice . 2-4Overview . 2-4Segment Usage – 835 . 2-4Segment and Data Element Description . 2-7Header . 2-8ST - Transaction Set Header. 2-8BPR – Financial Information. 2-8TRN: Reassociation Trace Number . 2-10REF: Receiver Identification . 2-10DTM: Production Date . 2-10N1: Payer Identification . 2-11N3: Payer Address . 2-11N4: Payer City, State, ZIP Code . 2-11PER: Payer Business Contact Information . 2-11PER: Payer Technical Contact Information . 2-11N1: Payee Identification . 2-12N3: Payee Address . 2-12N4: Payee City, State, ZIP Code . 2-12REF: Payee Additional Identification. 2-12Detail . 2-13LX: Header Number . 2-13CLP: Claim Payment Information . 2-13CAS: Claim Adjustment . 2-13NM1: Patient Name . 2-13NM1: Corrected Patient / Insured Name . 2-13NM1: Service Provider Name . 2-14NM1: Corrected Priority Payer Name . 2-14NM1: Other Subscriber Name . 2-14MIA: INPATIENT ADJUDICATION INFORMATION . 2-14MOA: Outpatient Adjudication Information . 2-14REF: Other Claim Related Identification . 2-15REF: Rendering Provider Identification . 2-15DTM: Statement From or To Date . 2-15DTM: Coverage Expiration Date . 2-15SVC: Service Payment Information . 2-15DTM: Service Date . 2-16CAS: Service Adjustment . 2-16REF: Service Identification . 2-16REF: Line Item Control Number . 2-16REF: Rendering Provider Information . 2-16LQ: Health Care Remark Codes . 2-17Summary . 2-17PLB: Provider Adjustment . 2-17SE: Transaction Set Trailer . 2-17Revision Date: January 2011Version: 3.0Page 2-2

Section 1: Revision HistoryDocumentVersionNumberRevision DateRevisionPageNumber(s)Reason for RevisionsRevisions Completed ByVersion 1.0ISDH HIPAAVersion 2.1ISDH HIPAAVersion 3.0January 2011Revision Date: January 2011Version: 3.0All5010 ImplementationISDH HIPAAPage 2-3

Companion Guide – 835 Remittance Advice TransactionSection 2: Health Care Claim PaymentAdviceOverviewThe ASC X12N 835 (005010X221A1) is the HIPAA-mandated transaction forsending an Electronic Remittance Advice (ERA) to providers.It is highly recommended that implementers have the following resources availableduring the development process: This document, Companion Guide – 835 Health Care Claim Remittance Advice ASC X12N 835 (005010X221A1)Segment Usage – 835The following matrix lists all segments available for creation with the 5010 versionof the 835 Health Care Claim Payment Advice IG. The guide includes a Usagecolumn that identifies segments that are required, situational, or not used by ISDH.A required segment element appears for all transactions. A situational segment isnot required for each type of transaction; however, a situational segment may berequired under certain circumstances. Any data in a segment identified in theUsage column with an X is never sent by the ISDH. Any segment identified in theUsage column as required or situational by the IG, and the ISDH, is explained indetail in this section of the companion guide.Table 1.1 – 835 SegmentsISDH UsageSegment IDLoop IDSegment NameR – RequiredS – SituationalX – Not UsedSTN/ATransaction iationTrace NumberRCURN/AForeign EFN/AVersionIdentificationXDTMN/AProduction DateSRevision Date: January 2011Version: 3.0Page 2-4

ISDH UsageSegment IDLoop IDSegment NameR – RequiredS – SituationalX – Not UsedN11000APayerIdentificationRN31000APayer AddressRN41000APayer, City, State,ZIP, CodeRREF1000AAdditional PayerIdentificationXPER1000APayer BusinessContactInformationSPER011000APayer TechnicalContactInformationRPER011000APayer WEB SiteXN11000BPayeeIdentificationRN31000BPayee AddressSN41000BPayee City, State,ZIP CodeRREF1000BPayee y MethodXLX2000Header NumberSTS32000Provider aryInformationXCLP2100Claim PaymentInformationRCAS2100Claim AdjustmentSNM12100Patient NameRNM12100Insured rvice ProviderNameSRevision Date: January 2011Version: 3.0Page 2-5

Companion Guide – 835 Remittance Advice TransactionISDH UsageSegment IDLoop IDSegment NameR – RequiredS – SituationalX – Not UsedNM12100Crossover CarrierNameXNM12100Corrected PriorityPayer NameSNM12100Other 100Other rIdentificationSDTM2100Statement From orTo DateSDTM2100CoverageExpiration DateSDTM2100Claim ReceivedDateXPER2100Claim VC2110Service PaymentInformationSDTM2110Service ficationSREF2110Line Item ControlNumberSRevision Date: January 2011Version: 3.0Page 2-6

ISDH UsageSegment IDLoop IDSegment NameR – RequiredS – SituationalX – Not lthcare h CareRemark CodesSPLBN/AProviderAdjustmentSSEN/ATransaction SetTrailerRSegment and Data Element DescriptionThis section contains a table representing any segment that is required or situational for theIndiana HIPAA implementation of the 835. Each segment table contains rows and columnsdescribing different elements of the segment.If a segment is not used by ISDH, the table for that segment will not be shown.Segment Name – The industry assigned segment name as identified in the IG.Segment ID – The industry assigned segment ID as identified in the IG.Loop ID – The loop where the segment should appear.Usage – Identifies the segment as required or situational.Segment Notes – A brief description of the purpose or use of the segmentincluding ISDH-specific usage.Example – An example of complete segment.Element ID – The industry assigned segment ID as identified in the IG.Usage – Identifies the data element as R-required, S-situational, or N/A-not used.Guide Description/Valid Values – Industry name associated with the data element.If no industry name exists, this is the IG data element name. This column also listsin BOLD the values and/or code set to use.Comments – Description of the contents of the data elements, including fieldlength.Revision Date: January 2011Version: 3.0Page 2-7

Companion Guide – 835 Remittance Advice TransactionHeaderSegmentNameST - Transaction Set HeaderSegment IDSTLoop IDN/AUsageRequiredSegmentNotesFollow the HIPAA and IG rules.SegmentNameBPR – Financial InformationSegment IDBPRLoop IDN/AUsageRequiredSegmentNotesSee ISDH specific rules below.Element IDBPR01UsageRGuide Description and ValidValuesTransaction handling codeI – Remittance information onlyH – Notification onlyBPR02RTotal actual provider paymentamountBPR03RCredit or debit flag codeCommentI – This code is issued for fee-forservice claims.H – This code is issued to passinformation only without anyreference to payment.C – CreditBPR04RPayment method codeACH – Automated Clearing HouseCHK – CheckNON – Non-Payment DataACH – This code is issued whenmoney is moved electronicallythrough the ACH, or to notify theprovider that an ACH transfer wasrequested. When this code is used,information in BPR05 throughBPR15 must also be included.CHK – This code is issued whenBPR01 contains I and indicates acheck was issued for payment.NON – This code is issued when theTransaction Handling Code (BPR01)is H, indicating that this isinformation only and no dollars are toRevision Date: January 2011Version: 3.0Page 2-8

Element IDUsageGuide Description and ValidValuesCommentbe moved.BPR05SPayment format codeRequired when BPR04 is ACHCCP – CashConcentration/Disbursement plusAddenda (CCD ) (ACH)BPR06SDepository financial institution (DFI)identification number qualifierRequired when BPR04 is ACH, BOPor FWT.01 – ABA transit routing numberincluding check digits (9)BPR07SSender DFI identifierThis element contains the identifyingnumber of the financial institutionand is issued when BPR04 containsACH; otherwise, the data elementwill not be returned. If used, thenumber is 074000065.BPR08SAccount number qualifierRequired when BPR04 is ACHDA – Demand depositBPR09SSender Bank Account NumberRequired when BPR04 is ACHBPR10SPayer identifierRequired when BPR04 is ACHFederal tax ID number 1356000158BPR11SOriginating company supplementalcodeNot used by ISDHBPR12SDepository financial institution (DFI)identification number qualifier.Required when BPR04 is ACH01 – ABA transit routing numberincluding check digits (9 digits)BPR13SReceiver or provider bank ID numberRequired when BPR04 is ACHBPR14SAccount number qualifierRequired when BPR04 is ACHDA – Demand depositBPR15SReceiver or provider account numberBPR16RCheck issue or EFT effective dateRequired when BPR04 is ACHin CCYYMMDD format.BPR17N/ABusiness function codeNot usedBPR18N/ADFI ID number qualifierNot usedBPR19N/ADFI identification numberNot usedBPR20N/AAccount number qualifierNot usedBPR21N/AAccount numberNot usedRevision Date: January 2011Version: 3.0Page 2-9

Companion Guide – 835 Remittance Advice TransactionSegmentNameTRN: Reassociation Trace NumberSegment IDTRNLoop IDN/AUsageRequiredSegmentNotesThis segment uniquely identifies this ment IDTRN01UsageRGuide Description and Valid ValuesTrace type code1 – Current transaction tracenumbersCommentsIdentifies the transaction beingreferenced.TRN02RCheck or EFT trace numberIf no payment is made, the text NOPAY and a date and time stamp areused instead.TRN03RPayer identifierThis is the ISDH federal tax IDnumber and is always preceded by1. It is identical to BPR10.Federal tax ID number 1356000158TRN04SOriginating company supplementalcodeSegmentNameREF: Receiver IdentificationSegment IDREFLoop IDN/AUsageSituationalSegmentNotesFollow the HIPAA and IG rules.SegmentNameDTM: Production DateSegment IDDTMLoop IDN/AUsageSituationalSegmentNotesFollow the HIPAA and IG rules.Revision Date: January 2011Version: 3.0Not used by ISDHPage 2-10

SegmentNameN1: Payer IdentificationSegment IDN1Loop ID1000AUsageRequiredSegmentNotesFollow the HIPAA and IG rules.SegmentNameN3: Payer AddressSegment IDN3Loop ID1000AUsageRequiredSegmentNotesFollow the HIPAA and IG rules.SegmentNameN4: Payer City, State, ZIP CodeSegment IDN4Loop ID1000AUsageRequiredSegmentNotesFollow the HIPAA and IG rules.SegmentNamePER: Payer Business Contact InformationSegment IDPER01Loop ID1000AUsageSituationalSegmentNotesFollow the HIPAA and IG rules.SegmentNamePER: Payer Technical Contact InformationSegment IDPER01Loop ID1000AUsageRequiredSegmentNotesFollow the HIPAA and IG rules.Revision Date: January 2011Version: 3.0Page 2-11

Companion Guide – 835 Remittance Advice TransactionSegmentNameN1: Payee IdentificationSegment IDN1Loop ID1000BUsageRequiredSegmentNotesFollow the HIPAA and IG rules.SegmentNameN3: Payee AddressSegment IDN3Loop ID1000BUsageSituationalSegmentNotesFollow the HIPAA and IG rules.SegmentNameN4: Payee City, State, ZIP CodeSegment IDN4Loop ID1000BUsageRequiredSegmentNotesFollow the HIPAA and IG rules.SegmentNameREF: Payee Additional IdentificationSegment IDREFLoop ID1000BUsageSituationalSegmentNotesFollow the HIPAA and IG rules.Revision Date: January 2011Version: 3.0Page 2-12

DetailSegmentNameLX: Header NumberSegment IDLXLoop ID2000UsageSituationalSegmentNotesFollow the HIPAA and IG rules.SegmentNameCLP: Claim Payment InformationSegment IDCLPLoop ID2100UsageRequiredSegmentNotesFollow the HIPAA and IG rules.SegmentNameCAS: Claim AdjustmentSegment IDCASLoop ID2100UsageSituationalSegmentNotesFollow the HIPAA and IG rules.SegmentNameNM1: Patient NameSegment IDNM1Loop ID2100UsageRequiredSegmentNotesFollow the HIPAA and IG rules.SegmentNameNM1: Corrected Patient / Insured NameSegment IDNM1Loop ID2100UsageSituationalSegmentNotesFollow the HIPAA and IG rules.Revision Date: January 2011Version: 3.0Page 2-13

Companion Guide – 835 Remittance Advice TransactionSegmentNameNM1: Service Provider NameSegment IDNM1Loop ID2100UsageSituationalSegmentNotesFollow the HIPAA and IG rules.SegmentNameNM1: Corrected Priority Payer NameSegment IDNM1Loop ID2100UsageSituationalSegmentNotesFollow the HIPAA and IG rules.SegmentNameNM1: Other Subscriber NameSegment IDNM1Loop ID2100UsageSituationalSegmentNotesFollow the HIPAA and IG rules.SegmentNameMIA: INPATIENT ADJUDICATION INFORMATIONSegment IDMIALoop ID2100UsageSituationalSegmentNotesFollow the HIPAA and IG rules.SegmentNameMOA: Outpatient Adjudication InformationSegment IDMOALoop ID2100UsageSituationalSegmentNotesFollow the HIPAA and IG rules.Revision Date: January 2011Version: 3.0Page 2-14

SegmentNameREF: Other Claim Related IdentificationSegment IDREFLoop ID2100UsageSituationalSegmentNotesFollow the HIPAA and IG rules.SegmentNameREF: Rendering Provider IdentificationSegment IDREFLoop ID2100UsageSituationalSegmentNotesFollow the HIPAA and IG rules.SegmentNameDTM: Statement From or To DateSegment IDDTMLoop ID2100UsageSituationalSegmentNotesFollow the HIPAA and IG rules.SegmentNameDTM: Coverage Expiration DateSegment IDDTMLoop ID2100UsageSituationalSegmentNotesFollow the HIPAA and IG rules.SegmentNameSVC: Service Payment InformationSegment IDSVCLoop ID2110UsageSituationalSegmentNotesFollow the HIPAA and IG rules.Revision Date: January 2011Version: 3.0Page 2-15

Companion Guide – 835 Remittance Advice TransactionSegmentNameDTM: Service DateSegment IDDTMLoop ID2110UsageSituationalSegmentNotesFollow the HIPAA and IG rules.SegmentNameCAS: Service AdjustmentSegment IDCASLoop ID2110UsageSituationalSegmentNotesFollow the HIPAA and IG rules.SegmentNameREF: Service IdentificationSegment IDREFLoop ID2110UsageSituationalSegmentNotesFollow the HIPAA and IG rules.SegmentNameREF: Line Item Control NumberSegment IDREFLoop ID2110UsageSituationalSegmentNotesFollow the HIPAA and IG rules.SegmentNameREF: Rendering Provider InformationSegment IDREFLoop ID2110UsageSituationalSegmentNotesFollow the HIPAA and IG rules.Revision Date: January 2011Version: 3.0Page 2-16

SegmentNameLQ: Health Care Remark CodesSegment IDLQLoop ID2110UsageSituationalSegmentNotesFollow the HIPAA and IG rules.SummarySegmentNamePLB: Provider AdjustmentSegment IDPLBLoop IDN/AUsageSituationalSegmentNotesFollow the HIPAA and IG rules.SegmentNameSE: Transaction Set TrailerSegment IDSELoop IDN/AUsageRequiredSegmentNotesFollow the HIPAA and IG rules.Revision Date: January 2011Version: 3.0Page 2-17

SVC 2110 Service Payment Information S DTM 2110 Service Date S CAS 2110 Service Adjustment S REF 2110 Service Identification S REF 2110 Line Item Control Number S . Revision Date: January 2011 Version: 3.0 Page 2-7 Segment ID Loop ID Segment Name ISDH Usage R – Required S

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