ICRs Contained in 45 CFR Part 162; HIPAA Standards for Electronic Transactions

X091A1

ICRs Contained in 45 CFR Part 162; HIPAA Standards for Electronic Transactions

OMB: 0938-0866

Document [pdf]

Download: pdf | pdf

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X091A1 • 835
HEALTH CARE CLAIM PAYMENT/ADVICE

National Electronic Data Interchange
Transaction Set Implementation Guide

A
D
D
E
N
D
A

Health Care Claim
Payment/Advice
835
ASC X12N 835 (004010X091A1)

October 2002
OCTOBER 2002

004010X091A1 • 835
HEALTH CARE CLAIM PAYMENT/ADVICE

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

$45.00 - Bound Document
$35.00 - Portable Document (PDF) on Diskette
Portable Documents may be downloaded at no charge.
Contact Washington Publishing Company for more Information.

1.800.972.4334
www.wpc-edi.com

© 2002 WPC
Copyright for the members of ASC X12N by Washington Publishing Company.
Permission is hereby granted to any organization to copy and distribute this material internally as long as this copyright statement is
included, the contents are not changed, and the copies are not sold.

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X091A1 • 835
HEALTH CARE CLAIM PAYMENT/ADVICE

Table of Contents
Introduction .................................................................................................. 5
Modified pages............................................................................................ 7

OCTOBER 2002

004010X091A1 • 835
HEALTH CARE CLAIM PAYMENT/ADVICE

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X091A1 835
HEALTH CARE CLAIM PAYMENT/ADVICE

1 Introduction to Modified Pages
This document is addenda to the X12N Health Care Claim Payment/Advice Implementation Guide, originally published May 2000 as 004010X091. As a result
of the post publication review process, items were identified that could be considered impediments to implementation. These items were passed to the X12N
Health Care Work Group that created the original Implementation Guide for their
review.
Modifications based on those comments were reflected in a draft version of the
Addenda to the X12N 004010X091 Implementation Guide. Since the X12N
004010X091 Implementation Guide is named for use under the Health Insurance
Portability and Accountability Act of 1996 (HIPAA), an NPRM Draft Addenda went
through a Notice of Proposed Rule Making (NPRM) comment process that began
on May 31, 2002. Only the modifications noted in the NPRM Draft Addenda were
considered in the NPRM and X12N review processes. No changes to the Addenda were necessary based on comments received during the NPRM process
and X12N’s own review processes. The Addenda was approved for publication
by X12N on October 10, 2002. When using the X12N Health Care Claim Payment/Advice Implementation Guide, originally published May 2000 as
004010X091 and incorporating the changes identified in the Addenda, the value
used in GS08 must be “004010X091A1".
Each of the changes made to the 004010X091 Implementation Guide has been
annotated with a note in red and a line pointing to the location of the change. For
convenience, the affected 004010X091 Implementation Guide page number is
noted at the bottom of the page. Please note that as a result of insertion or deletion of material Addenda pages may not begin or end at the same place as the
original referenced page. Because of this, Addenda pages are not page for page
replacements and the original pages should be retained.
Changes in the Addenda may have caused changes to the Data Element Dictionary and the Data Element Name Index (Appendix E in the original Implementation Guide), but these changes are not identified in the Addenda. Changes in the
Addenda may also have caused changes to the Examples and the EDI Transmission Examples (Section 4 in the original Implementation Guide), again these are
not identified in the Addenda.

OCTOBER 2002

004010X091A1 835
HEALTH CARE CLAIM PAYMENT/ADVICE

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X091A1 • 835 • 1000A • N1
PAYER IDENTIFICATION

PAYER
004010X091A1
IDENTIFICATION
• 835 • 1000A • N1

SITUATIONAL

N102

Name

1/60

Free-form name
INDUSTRY: Payer
SYNTAX:

R0203

Required if the National PlanID is not transmitted in N104.

1000090
SITUATIONAL

Name

N103

Identification Code Qualifier

1/2

Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX:

R0203, P0304

ADVISORY: Under

Note changed
1000091

most circumstances, this element is expected to be sent.

Required if the National PlanID is transmitted in N104.
CODE

DEFINITION

Health Care Financing Administration National
PlanID
Required if the National PlanID is mandated for use.
CODE SOURCE 540: Health Care Financing Administration
National PlanID

SITUATIONAL

N104

Identification Code

2/80

Code identifying a party or other code
INDUSTRY: Payer
SYNTAX:

Identifier

P0304

ADVISORY: Under

most circumstances, this element is expected to be sent.

COMMENT: This segment, used alone, provides the most efficient method of
providing organizational identification. To obtain this efficiency the “ID Code”
(N104) must provide a key to the table maintained by the transaction processing
party.

Note changed
1000092

Required if the National Plan ID is mandated for use.

NOT USED

N105

706

Entity Relationship Code

2/2

NOT USED

N106

Entity Identifier Code

2/3

OCTOBER 2002

Original Page Number 63 dated May 2000

004010X091A1 • 835 • 2110 • SVC
SERVICE PAYMENT INFORMATION

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

SERVICE
004010X091A1
PAYMENT
• 835 INFORMATION
• 2110 • SVC

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

SVC01

DATA
ELEMENT

C003

NAME

ATTRIBUTES

COMPOSITE MEDICAL PROCEDURE
IDENTIFIER

To identify a medical procedure by its standardized codes and applicable
modifiers

1128

Use the adjudicated Medical Procedure Code.

1230

This code is a composite data structure.

REQUIRED

SVC01 - 1

235

Product/Service ID Qualifier

2/2

Code identifying the type/source of the descriptive number used in
Product/Service ID (234)
INDUSTRY: Product

or Service ID Qualifier

The value in SVC01-01 qualifies the values in SVC01-02,
SVC01-03, SVC01-04, SVC01-05, and SVC01-06.

1101

CODE

DEFINITION

American Dental Association Codes
CODE SOURCE 135:

American Dental Association Codes

Jurisdiction Specific Procedure and Supply Codes
This is specific to Workman’s Compensation Claims.

1403
HC

Health Care Financing Administration Common
Procedural Coding System (HCPCS) Codes
Because the CPT codes of the American Medical
Association are also level 1 HCPCS codes, they are
reported under the code HC.

1288

CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System

International Classification of Diseases Clinical
Modification (ICD-9-CM) - Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure

New code value

Home Infusion EDI Coalition (HIEC) Product/Service
Code
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.

1091

Codes N1, N2, N3
and ND deleted

CODE SOURCE 513: Home Infusion EDI Coalition (HIEC)
Product/Service Code List

National Drug Code in 5-4-2 Format
CODE SOURCE 240:

National Drug Code by Format

National Uniform Billing Committee (NUBC) UB92
Codes
CODE SOURCE 132:

National Uniform Billing Committee (NUBC)

Codes

Original Page Number 140 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

REQUIRED

SVC06 - 1

004010X091A1 • 835 • 2110 • SVC
SERVICE PAYMENT INFORMATION

235

Product/Service ID Qualifier

2/2

Code identifying the type/source of the descriptive number used in
Product/Service ID (234)
INDUSTRY: Product

or Service ID Qualifier

The value in SVC06-01 qualifies the values in SVC06-02,
SVC06-03, SVC06-04, SVC06-05, and SVC06-06.

1103

CODE

DEFINITION

American Dental Association Codes
CODE SOURCE 135:

American Dental Association Codes

Jurisdiction Specific Procedure and Supply Codes
This is specific to Workman’s Compensation Claims.

1403
HC

1288

CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System

International Classification of Diseases Clinical
Modification (ICD-9-CM) - Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure

New code value

1091

CODE SOURCE 513: Home Infusion EDI Coalition (HIEC)
Product/Service Code List

Codes N1, N2, N3
and ND deleted
N4

National Drug Code in 5-4-2 Format
CODE SOURCE 240:

National Drug Code by Format

National Uniform Billing Committee (NUBC) UB92
Codes
CODE SOURCE 132:

National Uniform Billing Committee (NUBC)

Codes

National Uniform Billing Committee (NUBC) UB82
Codes
CODE SOURCE 132:

National Uniform Billing Committee (NUBC)

Codes

OCTOBER 2002

Original Page Number 143 dated May 2000

004010X091A1 • 835 • PLB
PROVIDER ADJUSTMENT

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X091A1
PROVIDER
ADJUSTMENT
• 835 • PLB

Use this code for the interest assessment for late
filing. Medicare Part A provides code “IP” in PLB032.

1309

Authorized Return
This monetary amount is the provider refund
adjustment. This adjustment acknowledges a refund
received from a provider for previous overpayment.
PLB03-2 should always contain an identifying
reference number when the value isused. PLB04
should contain a negative value. This adjustment
should always be offset by some other PLB
adjustment referring to the original refund request
or reason. For balancing purposes, the amount
related to this adjustment reason code must be
directly offset. Medicare A will provide code “PR” in
PLB03-2.

1310

New code value

Early Payment Allowance

Origination Fee
This is the claim transmission fee. This is used for
transmission fees that are not specific to or
dependent upon individual claims.

1000093

Applied to Borrower’s Account
See 2.2.10, Capitation and Related Payments or
Adjustments, for additional information. Use this
monetary amount for the loan repayment amount.

1311

Acceleration of Benefits
Use this code to reflect accelerated payment
amounts or withholdings. Withholding or payment
identification is indicated by the sign of the amount
in PLB04. A positive value represents a withholding.
A negative value represents a payment. Medicare
Part A will provide code “AP” for accelerated
payment amounts and code “AW” for accelerated
payment withholdings in PLB03-2.

1312

1313

Interest Penalty Charge

Original Page Number 166 dated May 2000

Rebate
Use this code for the refund adjustment. Medicare
Part A will provide code “RF” in PLB03-2.

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X091A1 • 835
HEALTH CARE CLAIM PAYMENT/ADVICE

Data elements are assigned a unique reference number. Each data element has
a name, description, type, minimum length, and maximum length. For ID type
data elements, this guide provides the applicable ASC X12 code values and their
descriptions or references where the valid code list can be obtained.
Each data element is assigned a minimum and maximum length. The length of
the data element value is the number of character positions used except as
noted for numeric, decimal, and binary elements.
The data element types shown in matrix A4, Data Element Types, appear in this
implementation guide.
SYMBOL
TYPE
Nn
Numeric
R
Decimal
ID
Identifier
AN
String
DT
Date
TM
Time
B
Binary
Matrix A4. Data Element Types

A.1.3.1.1

Numeric
A numeric data element is represented by one or more digits with an optional
leading sign representing a value in the normal base of 10. The value of a numeric data element includes an implied decimal point. It is used when the position of the decimal point within the data is permanently fixed and is not to be
transmitted with the data.
This set of guides denotes the number of implied decimal positions. The representation for this data element type is “Nn” where N indicates that it is numeric
and n indicates the number of decimal positions to the right of the implied decimal point.
If n is 0, it need not appear in the specification; N is equivalent to N0. For negative values, the leading minus sign (-) is used. Absence of a sign indicates a positive value. The plus sign (+) should not be transmitted.
EXAMPLE
A transmitted value of 1234, when specified as numeric type N2, represents a
value of 12.34.
Leading zeros should be suppressed unless necessary to satisfy a minimum
length requirement. The length of a numeric type data element does not include
the optional sign.

A.1.3.1.2

Decimal
A decimal data element may contain an explicit decimal point and is used for numeric values that have a varying number of decimal positions. This data element
type is represented as “R.”
The decimal point always appears in the character stream if the decimal point is
at any place other than the right end. If the value is an integer (decimal point at
the right end) the decimal point should be omitted. For negative values, the leading minus sign (-) is used. Absence of a sign indicates a positive value. The plus
sign (+) should not be transmitted.

OCTOBER 2002

Original Page Number A.5 dated May 2000

004010X091A1 • 835
HEALTH CARE CLAIM PAYMENT/ADVICE

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

Leading zeros should be suppressed unless necessary to satisfy a minimum
length requirement. Trailing zeros following the decimal point should be suppressed unless necessary to indicate precision. The use of triad separators (for
example, the commas in 1,000,000) is expressly prohibited. The length of a decimal type data element does not include the optional leading sign or decimal point.
EXAMPLE
A transmitted value of 12.34 represents a decimal value of 12.34.
New note

A.1.3.1.3

For implementation of this guide under the rules promulgated under the Health Insurance Portability and Accountability Act (HIPAA), decimal data elements in
Data Element 782 (Monetary Amount) will be limited to a maximum length of 10
characters including reported or implied places for cents (implied value of 00 after
the decimal point). Note the statement in the preceding paragraph that the decimal point and leading sign, if sent, are not part of the character count.

Identifier
An identifier data element always contains a value from a predefined list of codes
that is maintained by the ASC X12 Committee or some other body recognized by
the Committee. Trailing spaces should be suppressed unless they are necessary
to satisfy a minimum length. An identifier is always left justified. The representation for this data element type is “ID.”

A.1.3.1.4

String
A string data element is a sequence of any characters from the basic or extended
character sets. The significant characters shall be left justified. Leading spaces,
when they occur, are presumed to be significant characters. Trailing spaces
should be suppressed unless they are necessary to satisfy a minimum length.
The representation for this data element type is “AN.”

A.1.3.1.5

Date
A date data element is used to express the standard date in either YYMMDD or
CCYYMMDD format in which CC is the first two digits of the calendar year, YY is
the last two digits of the calendar year, MM is the month (01 to 12), and DD is the
day in the month (01 to 31). The representation for this data element type is “DT.”
Users of this guide should note that all dates within transactions are 8-character
dates (millennium compliant) in the format CCYYMMDD. The only date data element that is in format YYMMDD is the Interchange Date data element in the ISA
segment, and also used in the TA1 Interchange Acknowledgment, where the century can be readily interpolated because of the nature of an interchange header.

A.1.3.1.6

Time
A time data element is used to express the ISO standard time HHMMSSd..d format in which HH is the hour for a 24 hour clock (00 to 23), MM is the minute (00
to 59), SS is the second (00 to 59) and d..d is decimal seconds. The representation for this data element type is “TM.” The length of the data element determines the format of the transmitted time.
EXAMPLE
Transmitted data elements of four characters denote HHMM. Transmitted data
elements of six characters denote HHMMSS.

Original Page Number A.6 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
FUNCTIONAL GROUP HEADER
GS

004010X091A1 • 835 • GS
FUNCTIONAL GROUP HEADER

004010X091A1GROUP
FUNCTIONAL
GS
• 002 • HEADER

IMPLEMENTATION

FUNCTIONAL GROUP HEADER
Example: GS✽HP✽SENDER CODE✽RECEIVER
CODE✽19940331✽0802✽1✽X✽004010X091A1~

005
100
4

Example changed

STANDARD

GS Functional Group Header
Purpose: To indicate the beginning of a functional group and to provide control information
DIAGRAM

GS01

GS ✽

479

Functional
ID Code
M

GS07

GS02

2/2

455

GS08

✽ Responsible ✽
Agency Code
M

1/2

142

GS03

✽ Application ✽
Send’s Code
AN 2/15

AN 2/15

GS04

373

Date

✽
M

GS05

✽
8/8

337

Time
M

GS06

✽
4/8

Group Ctrl
Number
M

1/9

480

Ver/Release
ID Code
M

124

Application
Rec’s Code

AN 1/12

ELEMENT SUMMARY

USAGE

REQUIRED

REF.
DES.

GS01

DATA
ELEMENT

479

NAME

ATTRIBUTES

Functional Identifier Code

2/2

2/15

Code identifying a group of application related transaction sets
CODE

HP
REQUIRED

GS02

142

DEFINITION

Health Care Claim Payment/Advice (835)

Application Sender’s Code

Code identifying party sending transmission; codes agreed to by trading partners

Use this code to identify the unit sending the information.

1000009
REQUIRED

GS03

124

Application Receiver’s Code

2/15

Code identifying party receiving transmission. Codes agreed to by trading partners

Use this code to identify the unit receiving the information.

1000010
REQUIRED

GS04

373

Date

8/8

4/8

Date expressed as CCYYMMDD
SEMANTIC:

Use this date for the functional group creation date.

1000011
REQUIRED

GS04 is the group date.

GS05

337

Time

Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or
HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S =
integer seconds (00-59) and DD = decimal seconds; decimal seconds are
expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
SEMANTIC:

1000012

OCTOBER 2002

GS05 is the group time.

Use this time for the creation time. The recommended format is
HHMM.

Original Page Number B.8 dated May 2000

004010X091A1 • 835 • GS
FUNCTIONAL GROUP HEADER

REQUIRED

GS06

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

Group Control Number

1/9

Assigned number originated and maintained by the sender
The data interchange control number GS06 in this header must be
identical to the same data element in the associated functional group trailer,
GE02.

SEMANTIC:

REQUIRED

GS07

455

Responsible Agency Code

1/2

Code used in conjunction with Data Element 480 to identify the issuer of the
standard
CODE

X
REQUIRED

GS08

480

DEFINITION

Accredited Standards Committee X12

Version / Release / Industry Identifier Code

1/12

Code indicating the version, release, subrelease, and industry identifier of the EDI
standard being used, including the GS and GE segments; if code in DE455 in GS
segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6
are the release and subrelease, level of the version; and positions 7-12 are the
industry or trade association identifiers (optionally assigned by user); if code in
DE455 in GS segment is T, then other formats are allowed
CODE

New code value

004010X091A1 Draft Standards Approved for Publication by ASC
X12 Procedures Review Board through October
1997, as published in this implementation guide.

1091

DEFINITION

Original Page Number B.9 dated May 2000

When using the X12N Health Care Claim
Payment/Advice Implementation Guide, originally
published May 2000 as 004010X091 and
incorporating the changes identified in the Addenda,
the value used in GS08 must be “004010X091A1".

OCTOBER 2002

File Type	application/pdf
File Modified	2002-10-31
File Created	2001-08-31