835 Flat File - 5010A1 UPDATED 2/27/2018 · 835 Flat File - 5010A1 UPDATED 2/27/2018 1 Legend: Changed field highlighted in yellow Usa 4 405 R R R R R R R

835 Flat File - 5010A1UPDATED 2/27/2018

1

Legend: Changed field highlighted in yellow

Usa

405RRRR

R

R

R

RRRRR

RRRR

RRRR

Usa R

R

R

RR

RRR

N/U

RR

RRRSSSSSSS

18X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File-----------835 TR3 5010A1

Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)

Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.

NOTE: All COBOL PICs for "R" defined data elements must start at position 1

Not used by Part B115 9=TRN04105 10

BPR11 Originating Co Supplemental Code PIC X(9) AN 9--9BPR10 Payer Identifier PIC X(10) AN 10--10

70 3567 3

BPR09 Sender Bank Acct # PIC X(35) AN 1--35DABPR08 Acct # Qualifier PIC X(3) ID 1--3

55 1253 2

BPR07 Sender DFI Identifier PIC X(12) AN 3--1201BPR06 DFI ID # Qualifier PIC X(2) ID 2--2

43 10CCP,CTX40 3

BPR05 Payment Format Code PIC X(10) ID 1--10ACH,CHK,NONBPR04 Payment Method Code PIC X(3) ID 3--3

39 1C21 18

BPR03 Credit or Debit Flag Code PIC X(1) ID 1--1BPR02 Total Actual Provider Payment Amt

05 Total Actual Provider Payment Amt- Group PIC X(18)05 Total Actual Provider Payment Amt- Group REDEF REDEFINESTotal Actual Provider Payment Amt - Group10 Total Actual Provider Payment Amt PIC S9(8)V9910 Total Actual Provider Payment Amt Filler PIC X(8)

R 1--18

19 2C, D, H, I ,P, U, X1 18 1

BPR01 Transaction Handling Code PIC X(2) ID 1--269 BPRBPR Financial Information 1 ----------- 1

Added field ST03 RE: AtST03 Implementation Convention Reference AN 1-3522 9=SE0219 3

ST02 Transaction Set Control Number PIC X(9) AN 4--9835ST01 Transaction Set Identifier Code PIC X(3) ID 3--3

ST 1 18 1------------ 1 68ST Transaction Set Header 1

78 12005010X221A176 2

GS08 Version/Release/Industry ID code PIC X(12) AN 1--12XGS07 Responsible Agency Code PIC X(2) ID 1--2

67 9Increament by one; beginning at 001

59 8

GS06 Group Control NumberPIC 9(9)

N0 1--9

See ISA010GS05 Time PIC 9(8) TM 4--851 8See ISA09

Start Length Record Repeat CommentGS04 Date PIC 9(8) DT 8--8

Values Page # Loop ID Loop Seq Seg ID Seg. Seq.Element COBOL PIC ID Min/Max Loop Loop RepeatX12 Flat File----------- 18X12 Element Attributes---------------------------------------------------------------------------

835 TR3 5010A1




36 15Application Receiver's Code15

GS03 Application Receiver's Code PIC X(15) AN 2--1521GS02 Application Sender's Code PIC X(15) AN 2--15 Application Sender's Code19 2HP

18 1GS01 Functional Identifier Code PIC X(2) ID 2--2

GS 1GS Functional Group Header 1 -----------

1104ISA16 Component Element Separator PIC X(1) 1--1 Translator Generated103 1P,T

1ISA15 Usage Indicator PIC X(1) ID 1--1

102ISA14 Acknowledgement Requested PIC X(1) ID 1--1 093 9

YJJJ00000 where Y is the last digit of the cycle year, JJJ is the Julian date of the cycle and 00000 is a

sequential number that starts with 00001 and increments by 1.

5

ISA13 Interchange Control Number

PIC 9(9)

N0 9--9

88ISA12 Interchange Control Version Number PIC X(5) ID 5--5 0050187 1(Translator Generated)

4ISA11 Repetition Separator PIC X(1) ID 1--1

83Format is YYMMDD with CC (20) appended

ISA10 Interchange Time PIC 9(4) TM 4--4 Interchange Time (Translator Generated)77 6Interchange Date (Translator Generated)

15ISA09 Interchange Date PIC 9(6) DT 6--6

62ISA08 Interchange Receiver ID PIC X(15) AN 15--15 Interchange Receiver ID

60 201,14,20,27,28,29,30,33,ZZ

15

ISA07 Interchange ID Qualifier PIC X(2) ID 2--2

45ISA06 Interchange Sender ID PIC X(15) AN 15--15 Interchange Sender ID

43 201,14,20,27,28,29,30,33,ZZ

10

ISA05Interchange ID Qualifier

PIC X(2) ID 2--2

33ISA04 Security Information PIC X(10) AN 10--10 Blank31 200

10ISA03 Security Information Qualifier PIC X(2) ID 2--2

21ISA02 Authorization Information PIC X(10) AN 10--10 Blank19 200

18 1ISA01 Authorization Information Qualifier PIC X(2) ID 2--2

ISA 1ISA Interchange Control Header 1 --------4 46 4

Length Record Repeat CommentPage # Loop ID Loop Seq Seg ID Seg. Seq. Start

835 TR3 5010A1

Element COBOL PIC ID Min/Max Loop Loop Repeat Values

18X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File-----------


2

Legend: Changed field highlighted in yellow835 TR3 5010A1

Usa S

SSS

RN/U

RRRRS

S

SRR

N/U

SR

R

N/U

Usage Req

SR

RN/U

RR

R

S

S

N/U

RR

S

RR

R

R

S

N/UN405- Location Qualifier ID 1-2

66 3

15

N404 Country Code PIC X(3) ID 2--3

51N403 Payer Postal Zone or ZIP Code PIC X(15) ID 3--15

49 2

30

N402 Payer State Code PIC X(2) ID 2--2

19N401 Payer City Name PIC X(30) AN 2--30N4 1 18 190 1000AN4 Payer City, State, Zip 1 1000A

74 55

55

N302 Payer Address Line PIC X(55) AN 1--55

19N301 Payer Address Line PIC X(55) AN 1--55N3 1 18 189 1000AN3 Payer Address 1 1000A

-NM106

N105- Entity Relationship Code ID 2--2

84 80

2

N104 Payer Identifier PIC X(80) AN 2--80

82

All names expanded to 60 per HIGLAS

N103 ID Code Qualifier PIC X(2) ID 1--2 XV

22 60

3

N102 Payer Name PIC X(60) AN 1--60

19N101 Entity Identifier Code PIC X(3) ID 2--3 PRN1 1 18 11 87 1000AN1 Payer Identification 1 1000A

-DTM06

DTM03- Time TM 4-822 8CCYYMMDD

3

DTM02 Production Date

05 Production Date - Group PIC X(8)05 Production Date - Group - REDEF REDEFINESProduction Date - Group 10 Production DatePIC 9(8)

DT 8--8

19DTM01 Date Time Qualifier PIC X(3) ID 3--3 405DTM 1 18 11 85DTM Production Date 1 -----------

Length

Record Repeat

Comment

-REF04

Page #

Loop ID

Loop Seq Seg ID Seg. Seq. Start

Element Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values





REF03- Description AN 1-80

22 50

3

REF02 Version ID Code PIC X(50) AN 1--50

84 19REF01 Receiver ID Qualifier PIC X(3) ID 2--3 F2REF 1 18 11REF Version Identification 1 -----------

-REF04REF03- Description AN 1-80

22 503

REF02 Receiver Identifier PIC X(50) AN 1--5082 19REF01 Receiver ID Qualifier PIC X(3) ID 2--3 EV

REF 1 18 11REF Reference Identification 1 -----------

Medicare does not use thCUR1 N/A 79CUR Foreign Currency Information 1 -----------

Change max from 30 to 50 RE: Attahment w/81 50=BPR01110

TRN04 Originating Co Supplemental Code PIC X(50) AN 1--5071TRN03 Payer Identifier PIC X(10) AN 10--1021 50

2TRN02 Check or EFT Trace # PIC X(50) AN 1--50

19TRN01 Trace Type Code PIC X(2) ID 1--2 1TRN 1 18 11 77TRN Reassociation Trace Number 1 -----------

-BPR21BPR17- Business Function Code ID 1-3

176 8

35

BPR16

Check Issue or EFT Effective Date

05 Check Issue or EFT Effective Date - Group PIC X(8)05 Check Issue or EFT Effective Date - Group REDEF REDEFINESCheck Issue or EFT Effective Date- Group10 Check Issue or EFT Effective Date PIC 9(8)

DT 8--8

141BPR15 Receiver or Provider Acct # PIC X(35 AN 1--35138 3DA,SG

12BPR14 Acct # Qualifier PIC X(3) ID 1--3

126BPR13 Receiver or Provider Bank ID # PIC X(12) AN 3--12124 201

Length Record Repeat CommentBPR12 DFI ID # Qualifier PIC X(2) ID 2--2

Page # Loop ID Loop Seq Seg ID Seg. Seq. StartElement COBOL PIC ID Min/Max Loop Loop Repeat Values


3


Usage Req

S

SR

R

N/U

SR

S

S

S

S

S

S

S

N/U

RR

S

S

S

S

S

S

S

Usage Req

N/U

SR

N/U

R

R

N/U

RR

R

R

R

N/U

SR

S

SR 19 30

1 18 1N401 Payee City Name PIC X(30) AN 2--30

105 1000B N4N4 Payee City,State,Zip 1 1000B

74 55N302 Payee Address Line PIC X(55) AN 1--55

19 551 18 1

N301 Payee Address Line PIC X(55) AN 1--55

104 1000B N3N3 Payee Address 1 1000B

-N106

84 80

N105- Entity Relationship Code ID 2--2

N104 Payee ID Code PIC X(80) AN 2--80

82 2XX, FI, XV

22 60 All names expanded to 60 per HIGLAS

N103 Identification Code Qualifier PIC X(2) ID 1--2

N102 Payee Name PIC X(60) AN 1--60

19 3PE1 18 1

N101 Entity Identifier Code PIC X(3) ID 2--3

102 1000B N1N1 Payee Identification 1 1000B 1

- PER09

PER05- Cummunication Number Qualifier ID 2--2

83 256

81 2

PER04 Payer Contact Communication#

PIC X(256) AN 1-256

URPER03 Communication # Qualifier PIC X(2) ID 2--2

21 60

19 2

PER02 Name PIC X(60) AN 1-60

ICPER01 Contact Function Code PIC X(2) ID 2--2PER 1 18 11000A 100 1000APER Payer Web Site 1

Start Length

Record Repeat

Comment

PER09 Contact Inquiry Reference AN 1-20

Values Page #

Loop ID

Loop Seq Seg ID Seg. Seq.

Element Identifier

COBOL PIC

ID Min/Max Loop

Loop RepeatX12 Flat File----------- 18X12 Element Attributes---------------------------------------------------------------------------

835 TR3 5010A1




599 256

2


PIC X(256) AN 1-256

597PER07 Communication Number Qualifier 3 PIC X(2) ID 2--2 EM, EX, FX, UR

341 256

2


PIC X(256) AN 1-256

339PER05 Communication Number Qualifier 2 PIC X(2) ID 2--2 EM, EX, FX, TE, UR

83 256

2


PIC X(256) AN 1-256

81


PER03 Communication # Qualifier PIC X(2) ID 2--2 EM, TE, UR

21 60

2

PER02 Payer Contact Name PIC X(60) AN 1-60

19PER01 Contact Function Code PIC X(2) ID 2--2 BLPER 1 18 197 1000APER Payer Technical Contact Information 1 1000A

256


599PER08 Payer Contact Communication#

PIC X(256) AN 1-256

597 2EX

256

PER07 Communication Number Qualifier 3 PIC X(2) ID 2--2


PIC X(256) AN 1-256

339 2EM,EX,FX,TE

256

PER05 Communication Number Qualifier 2 PIC X(2) ID 2--2


PIC X(256) AN 1-256

81 2EM,FX,TE

60 All names expanded to 60 per HIGLAS

PER03 Communication # Qualifier PIC X(2) ID 2--2

21PER02 Payer Contact Name PIC X(60) AN 1-60

19 2CX18 1

PER01 Contact Function Code PIC X(2) ID 2--2

94 1000A PER 1PER Payer Business Contact Information 1 1000A

-REF04

50

REF03- Description AN 1--80

22REF02 Additional Payer ID PIC X(50) AN 1--50

19 32U18 4

REF01 Reference Identification Qualifier PIC X(3) ID 2--3

92 1000A REF 1REF Additional Payer Identification 4 1000A

369N407 Country Subdivision Code PIC X(3) ID 1--3

Length

Record Repeat

Comment

-N406

Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values






4


S

S

S

N/U

Usage Req

S

SR

R

N/U

S

N/U

S

R

SR

R

R

Usage Req

R

RN/U

N/U

N/U

N/U

N/U

N/U

N/U

SN/U

SN/U

Usage Req

S

SN/U

S 18 Only Part A184TS320 Total Professional Component Amount 05 Total Professional Component Amo nt Gro p PIC X(18)

R 1--18

18 Only Part ATS319 Total Deductible Amount R 1--18

166

Only Part A

TS318 Total HCPCS Payable Amount 05 Total HCPCS Payable Amount G PIC X(18)

R 1--18

148 18

Length

Record Repeat

Comment

TS317 Total HCPCS Reported Charge Amount 05 Total HCPCS Reported Charge Amo nt Gro p

R 1--18

Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values





130 18 Only Part A

TS316 Total Coinsurance AmountTS315 Total Non-Lab Charge Amount 05 Total Non-Lab Charge Amount -

G PIC X(18)R 1--18

112 18 Only Part A

TS314 Total Blood Deductible Amount R 1--18TS313 Total MSP Payer Amount 05 Total MSP Payer Amount -

Gro p PIC X(18)R 1--18

TS312 Total Gramm-Rudman Reduction AmountTS 311 Total Contractual Adjustment AmountTS 310 Total Interest Amount

TS 309 Total Provider Amount

TS 308 Total Denied Charge Amount

TS307 Total Noncovered Charge Amount

94 18TS306 Total Covered Charge AmountTS305 Total Claim Change Amount 05 Total Claim Change Amount -

Gro p PIC X(18)R 1--18

79 15

Start Length

Record Repeat

Comment

TS304 Total Claim Count 05 Total Claim Count - Group PIC X(15)

R 1--15

Values Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop


835 TR3 5010A1




71 8CCYYMMDD

2 Part B will use either 11 or 99

TS303 Fiscal Period Date 05 Fiscal Period Date - Group PIC (8)

DT 8--8

69

Legacy in case of VA pricing

TS302 Facility Code Value PIC X(2) AN 1--2 11,99, Type of Bill

19 50NPI18 1

TS301 Provider Identifier PIC X(50) AN 1--50

112 2000 TS3 1TS3 Provider Summary Information 1 2000 1

6 FISS uses TTYYMM -Facilit Code/ ear/Month MCS ses 1 for

19LX01 Assigned # 05 Assigned Number -GROUP PIC X(6)

N0 1--6 0,1, TTYYMM

LX 1 18 1>1 111 2000LX Header Number 1 2000

-RDM05

RDM04 Reference Identifier

81 256

60

RDM03 Communication Number PIC X(256) AN 1--256

21RDM02 Name PIC X(60) AN 1--60

19 2BM, EM, FT, OL18

RDM01 Report Transmission Code PIC X(2) ID 1--2

109 1RDM Remittance Delivery Method 1 1000B

-REF04

50

REF03- Description AN 1 80

22REF02 Additional Payee ID # PIC X(50) AN 1--50

19 3TJ18 >1

REF01 Reference Identification Qualifier PIC X(3) ID 2--3

107 1000B REF 1REF Payee Additional Identification >1 1000B

3 Payee Subdivision code per HIGLAS request69N407 Country Subdivision Code PIC X(3) ID 1--3

Length

Record Repeat

Comment

-N406

Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values





66 3

N405- Location Qualifier ID 2--2

N404 Country Code PIC X(3) ID 2--3

51 15

49 2

N403 Payee Postal Zone or ZIP Code PIC X(15) ID 3-15

N402 Payee State Code PIC X(2) ID 2--2


5


S

S

Usage Req

S

S

S

S

S

S

Usage Req

S

S

S

S

S

S

Usage Req

S

S

S

S

S

S

Usage Req

S

S

S

S

RR

R

R




59 18

57 2

CLP03 Total Claim Charge Amount 05 Total Claim Charge Amount - G PIC

R 1--18

1,2,3,4, 19, 20, 21, 22, 23CLP02 Claim Status Code PIC X(2) ID 1--2

19 381 18 1

CLP01 Patient Control # PIC X(38) AN 1--38

123 2100 CLPCLP Claim Level Data 1 2100 >1

322 18TS219 Total PPS DSH DRG Amount 05 Total PPS DSH DRG Amount - G PIC

R 1--18

304 18

286 18

TS218 Total PSP Capital HSP DRG Amount 05 Total PSP Capital HSP DRG A t G PIC

R 1--18

TS217 Total PPS Capital FSP DRG Amount 05 Total PPS Capital FSP DRG Amo nt Gro p PIC

R 1--18

271 15

Start Length

Record Repeat

Comment

TS216 Average DRG Weight 05 Average DRG Weight - Group PIC X(15)

R 1--15

Values Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop


835 TR3 5010A1




253 18

15

TS215 Total MSP Pass-Through Amount 05 Total MSP Pass-Through A t G PIC

R 1--18

238TS214 Total Noncovered Day Count 05 Total Noncovered Day Count- Gro p PIC

R 1--15

223 15

15

TS213 Total Covered Day Count 05 Total Covered Day Count - Gro p PIC X(15)

R 1--15

208TS212 Total Cost Report Day Count 05 Total Cost Report Day Count - G PIC

R 1--15

193 15

15

TS 211 Total Discharge Count 05 Total Discharge Count - Group PIC X(15)

R 1--15

178

Comment

TS 210 Average DRG Length of Stay 05 Average DRG Length of Stay - Gro p PIC

R 1--15

Seg ID Seg. Seq. Start Length

Record RepeatLoop Repeat

Values Page #

Loop ID

Loop Seq

Element Identifier

COBOL PIC

ID Min/Max Loop





160 18TS 209 Total Cost Outlier Amount 05 Total Cost Outlier Amount - G PIC X(18)

R 1--18

142 18

127 15

TS 208 Total Day Outlier Amount 05 Total Day Outlier Amount - Gro p PIC X(18)

R 1--18

TS207 Total Outlier Day Count 05 Total Outlier Day Count - G PIC X(15)

R 1--15

109 18

91 18

TS206 Total Indirect Medical Education Amount 05 Total Indirect Medical Ed ti A t G

R 1--18

TS205 Total Capital Amount 05 Total Capital Amount - Group PIC X(18)

R 1--18

73 18

Start Length

Record Repeat

Comment

TS204 Total Disproportionate Amount 05 Total Disproportionate Amount - Gro p PIC X(18)

R 1--18

Values Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop


835 TR3 5010A1




55 18

18

TS203 Total Hospital Specifc Amount 05 Total Hospital Specifc Amount - G PIC X(18)

R 1--18

37TS202 Total Federal Specific Amount 05 Total Federal Specific Amount - Gro p PIC X(18)

R 1--18

19 18

18 1 N/U for Part B

TS201 Total DRG Amount 05 Total DRG Amount - Group PIC X(18)

R 1--18

117 2000 TS2 1TS2 Provider Supplemental Summary Info 1 2000

18 Only Part A253

Only Part A

TS324 Total PIP Adjustment Amount 05 Total PIP Adjustment Amount - G PIC

R 1--18

238 15

Length

Record Repeat

Comment

TS323 Total PIP Claim Count 05 Total PIP Claim Count - Group PIC X(15)

R 1--15

Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values





18 Only Part A220

Only Part A

TS322 Total Patient Reimbursement Amount 05 Total Patient Reimbursement Amo nt Gro p PIC

R 1--18

202 18TS321 Total MSP Patient Liability Met Amount 05 Total MSP Patient Liability Met A t G PIC

R 1--18


6


Usage Req

R

SR

S

S

S

N/U

S

S

SN/U

SR

R

Usage Req

R

SS

S

SS

S

S

Usage Req

S

S

SS

S

SS

S

Usage Req

S

RR

R

S

S All last names expanded to 35 per83 35


NM104 Patient First Name PIC X(35) AN 1--35

NM103 Patient Last Name PIC X(60) AN 1--60

22 11

19 3

NM102 Entity Type Qualifier PIC X(1) ID 1--1

QCNM101 Entity Identifier Code PIC X(3) ID 2--3NM1 1 18 12100 137 2100NM1 Patient Name 1

234 15

Start Length

Record Repeat

Comment

CAS19 Adjustment Quantity 05 Adjustment Quantity - Group PIC X(15)

R 1--15

Values Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop


835 TR3 5010A1




216 18

5

CAS18 Adjustment Amount 05 Adjustment Amount - Group PIC X(18)

R 1--18

211CAS17 Adjustment Reason Code PIC X(5) ID 1--5196 15

18


R 1--15

178CAS15 Adjustment Amount 05 Adjustment Amount - Group PIC X(18)

R 1--18

173 515

CAS14 Adjustment Reason Code PIC X(5) ID 1--5158CAS13 Adjustment Quantity 05 Adjustment Quantity - Group

PIC X(15)R 1--15

140 18

5


R 1--18

135

Comment

CAS11 Adjustment Reason Code PIC X(5) ID 1--5



Values Page #

Loop ID

Loop Seq

Element Identifier

COBOL PIC

ID Min/Max Loop





120 15CAS10 Adjustment Quantity 05 Adjustment Quantity - Group PIC X(15)

R 1--15

102 18

97 5


R 1--18

CAS08 Adjustment Reason Code PIC X(5) ID 1--582 15

64 18


R 1--15


R 1--18

59 544 15


PIC X(15)R 1--15

26 18

Start Length

Record Repeat

Comment


R 1--18

Values Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop


835 TR3 5010A1




21 5

2 Group code CR has been deleted


19CAS01 Claim Adjustment Group Code PIC X(2) ID 1--2 CO, OA, PRCAS 1 18 99129 2100CAS Claim Adjustment 99 2100

10CLP14 Yes/No Condition or Response Code ID 1--1

187

Part A only

CLP13 Discharge Fraction 05 Discharge Fraction - Group PIC X(10)

R 1--10

172 15

4 Part A only

CLP12 DRG Weight 05 DRG Weight - Group PIC X(15)

R 1--15

168CLP11 DRG Code PIC X(4) ID 1--4

1 Required when the information was

CLP10 Patient Status Code ID 1-2

167CLP09 Claim Frequency Code (3rd position of TOB) PIC X(1) ID 1--1

165 2

50

CLP08 Facility Code Value PIC X(2) AN 1--2

115CLP07 Payer Claim Control # PIC X(50) AN 1--50

113 2MA/MB18

CLP06 Claim Filling Indicator Code PIC X(2) ID 1--295CLP05 Patient Responsibility Amount 05 Patient Responsibility Amount -

G PIC X(18)R 1--18

77 18

Length

Record Repeat

Comment

CLP04 Claim Payment Amount 05 Claim Payment Amount - G PIC X(18)

R 1--18

Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values



7


S

N/U

S

S

S

N/U

S

SR

R

S

S

S

N/U

S

Usage Req

S

S

N/U

SR

R

S

S

S

N/U

S

R

R

N/U

SR

R

R

N/U

N/U

N/U

N/U

R

R

N/U

Usage Req

SR

R 22 12

19 3


PRNM101 Entity Identifier Code PIC X(3) ID 2--3NM1 1 18 12100 153 2100NM1 Corrected Priority Payer Name 1

Start Length

Record Repeat

Comment

-NM112

Values Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop


835 TR3 5010A1




80

NM110- Entity Relathionship Code ID 2--2

85NM109 COB Carrier Identifier PIC X(80) AN 2--80

83 2PI,XVNM108 ID Code Qualifier PIC X(2) ID 1--2

NM107 Name suffix AN 1-10

NM106 Name Prefix AN 1-10

NM105 Middle name AN 1-25

60 All names expanded to 60 per HIGLAS

NM104 First name AN 1-35

23NM103 COB Carrier Name PIC X(60) AN 1-60

22 12

3


19NM101 Entity Identifier Code PIC X(3) ID 2--3 TTNM1 1 18 1150 2100NM1 Crossover Carrier Name 1 2100

-NM112

NM110- Entity Relationship Code ID 2--2

155 80NPI

2

NM109 Rendering Provider Identifier PIC X(80) AN 2--80

153NM108 ID Code Qualifier PIC X(2) ID 1--2 XX

143 10NM107 Rendering Provider Name Suffix PIC X(10) AN 1--10

Required when NM102=1, and NM103


118 25

35 All last names expanded to 35 per

NM105 Rendering Provider Middle Name PIC X(25) AN 1--25

83


NM104 Rendering Provider First Name PIC X(35) AN 1-35

23 60

1

NM103 Rendering Provider Last/Org Name PIC X(60) AN 1-60

22NM102 Entity Type Qualifier PIC X(1) ID 1--1 1, 2

19 38218 1

NM101 Entity Identifier Code PIC X(3) ID 2--3

146 2100 NM1 1NM1 Service Provider Name 1 2100

-NM112

80Please see Attachment 3 w CR 9700 to determine when to provide the MBI in this field.


155NM109Corrected Ins Identification Indicator PIC X(80)

AN 2--80

153 2C

Length

Record Repeat

Comment

NM108 Identification Code Qualifier PIC X(25) ID 1--2

Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values





143 10NM107 Corrected Patient Name Suffix PIC X(10) AN 1--10


118 25

83 35 All last names expanded to 35 per

NM105 Corrected Patient/Ins Middle Name PIC X(25) AN 1--25


NM104 Corrected Patient/Ins First Name PIC X(35) AN 1--35

23 60

22 1

NM103 Corrected Patient/Ins Last Name PIC X(60) AN 1--60

1NM102 Entity Type Qualifier PIC X(1) ID 1--1

19 3741 18 1

NM101 Entity Identifier Code PIC X(3) ID 2--3

143 2100 NM1NM1 Corrected Patient/Insured Name 1 2100

Not used by MedicareN/A 140 2100NM1 Insured's Name 1 2100

-NM112

155 80


HIC #, MBINM109 Patient Identifier PIC X(80) AN 2--80

153 2MI143 10

NM108 ID Code Qualifier PIC X(2) ID 1--2

NUNM107 Patient Name Suffix PIC X(10) AN 1--10

118 25


NM105 Patient Middle Name PIC X(2) AN 1--25


8


R

N/U

N/U

N/U

N/U

R

R

N/U

S

R

S

Usage Req

S

SS

S

S

S

X12 Flat File----------- 18X12 Element Attributes---------------------------------------------------------------------------835 TR3 5010A1




171 18

18

MIA08 CLAIM PPS CAPITAL AMOUNT

05 CLAIM PPS CAPITAL AMOUNT - Group PIC X(18)05 CLAIM PPS CAPITAL AMOUNT REDEF REDEFINESCLAIM PPS CAPITAL AMOUNT -Group10 CLAIM PPS CAPITAL AMOUNT PICS9(8)V9910 CLAIM PPS CAPITAL R 1--18

153MIA07 CLAIM MSP PASS THRU AMT 05 CLAIM MSP PASS THRU AMT Gro p PIC

R 1--18

135 18

50

MIA06 CLAIM DSH AMOUNT 05 CLAIM DSH AMOUNT - Gro p PIC X(18)

R 1--18

85MIA05 CLAIM PAYMENT REMARK CD PIC X(50) AN 1--5067 18

15

MIA04 CLAIM DRG AMOUNT

05 CLAIM DRG AMOUNT - Group PIC X(18)05 CLAIM DRG AMOUNT REDEF REDEFINESCLAIM DRG AMOUNT -Group10 CLAIM DRG AMOUNT PIC S9(8)V9910 CLAIM DRG AMOUNT Filler PIC X(8)

R 1--18

52

Comment

MIA03 Lifetime Psychiatric Days Count

05 Lifetime Psychiatric Days Count - Group PIC X(15)05 Lifetime Psychiatric Days Count REDEF REDEFINESLifetime Psychiatric Days Count - Group10 Lifetime Psychiatric Days Count PIC S9(3)10 Lifetime Psychiatric Days Count Filler PIC X(12)

R 1--15



Values Page #

Loop ID

Loop Seq

Element Identifier

COBOL PIC

ID Min/Max Loop





34 18MIA02 PPS Operating Outlier Amount

05 PPS Operating Outlier Amount - Group PIC X(18)05 PPS Operating Outlier Amount REDEF REDEFINESPPS Operating Outlier Amount - Group10 PPS Operating Outlier Amount PICS9(8)V9910 PPS Operating Outlier

R 1--18

19 15

1 18 1 either MIA or MOA but not both

MIA01 Covered Days or Visits Count 05 Covered Days or Visits Count - Gro p PIC X(15)

R 1--15

159 2100 MIAMIA Inpatient Adjudication Information 1 2100

Not used by MedicareN/A 156NM1 Other Subscriber Name

-NM112

85 80

NM110- Entity Relationship Code ID 2-2

NM109 Corrected Priority Payer ID PIC X(80) AN 2--80

83 2PI,XVNM108 ID Code Qualifier PIC X(2) ID 1--2

NM107 Name suffix AN 1-10


NM105 middle name AN 1-25


NM104 First name AN 1-35

NM103 Corrected Priority Payer Name PIC X(60) AN 1--60


9


Usage Req

S

S

S

S

S

Usage Req

S

S

S

S

S

Usage Req

SS

S

S

S

S

S 1 18 1 Inpatient Claims. Use either MIA or MOA but166 2100 MOAMOA Outpatient Adjudication Information 1 2100

584 18MIA24 PPS CAPITAL EXCEPTION AMT

05 PPS CAPITAL EXCEPTION AMT- Group PIC X(18)05 PPS CAPITAL EXCEPTION AMT REDEF REDEFINESPPS CAPITAL EXCEPTIONAMT -Group10 PPS CAPITAL EXCEPTION AMT PIC S9(8)V9910 PPS CAPITAL EXCEPTION AMT Filler PIC X(8)

R 1--18

534 50

484 50

MIA23 CLAIM PAYMENT REMARK CD X(5) PIC X(50) AN 1--50


434 50

384 50


MIA20 CLAIM PAYMENT REMARK CD X(5) PIC X(50) AN 1--50366 18

Start Length

Record Repeat

Comment

MIA19 NON PAY PROF COMP AMT

05 NON PAY PROF COMP AMT - Group PIC X(18)05 NON PAY PROF COMP AMT REDEF REDEFINESNON PAY PROF COMP AMT -Group10 NON PAY PROF COMP AMT PIC S9(8)V9910 NON PAY PROF COMP AMT Filler PIC X(8)

R 1--18

Values Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop


835 TR3 5010A1




348 18

18

MIA18 CLAIM INDIRECT TEACHING

05 CLAIM INDIRECT TEACHING - Group PIC X(18)05 CLAIM INDIRECT TEACHING REDEF REDEFINESCLAIM INDIRECT TEACHING -Group10 CLAIM INDIRECT TEACHING PICS9(8)V9910 CLAIM INDIRECT TEACHING Filler PIC

R 1--18

330MIA17 CLAIM PPS OUTLIER AMOUNT 05 CLAIM PPS OUTLIER AMOUNT G

R 1--18

312 18

15

MIA16 PPS OPER FSP SPEC DRG AMT 05 PPS OPER FSP SPEC DRG AMT Gro p PIC

R 1--18

297MIA15 COST REPORT DAY COUNT 05 COST REPORT DAY COUNT Gro p PIC X(15)

R 1--15

279 18

Length

Record Repeat

Comment

MIA14 PPS OPER HSP SPEC DRG AMT S9(8)V99 05 PPS OPER HSP SPEC DRG AMT G PIC

R 1--18

Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values





261 18

243 18

MIA13 PPS CAPITAL IME AMOUNT 05 PPS CAPITAL IME AMOUNT - Gro p PIC

R 1--18

MIA12 OLD CAPITAL AMOUNT 05 OLD CAPITAL AMOUNT - G PIC X(18)

R 1--18

225 18

207 18

MIA11 PPS CAPITAL DSH DRG AMT 05 PPS CAPITAL DSH DRG AMT G PIC

R 1--18

MIA10 PPS CAPITAL HSP DRG AMT 05 PPS CAPITAL HSP DRG AMT Gro p

R 1--18

189 18

Start Length

Record Repeat

Comment

MIA09 PPS CAPITAL FSP DRG AMT 05 PPS CAPITAL FSP DRG AMT Gro p

R 1--18

Values Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat


10


S

SS

S

S

Usage Req

S

S

S

S

SR

R

S

SR

RN/U

Usage Req

SR

R 22 8CCYYMMDD

19 3

DTM02 Coverage Expiration Date

05 Coverage Expiration Date - Group PIC x(8)05 Coverage Expiration Date

DT 8--8

036DTM01 Date/Time Qualifier PIC X(3) ID 3--3DTM 1 18 12100 175 2100

Start Length

Record Repeat

Comment

DTM Coverage Expiration Date 1

Values Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop


835 TR3 5010A1




-DTM06

8DTM03- Time TM 4-8

22DTM02 Claim Date 05 Claim Date - Group PIC X(8)05 Claim Date Gro p REDEF

DT 8--8 CCYYMMDD

19 3232, 23318 2

DTM01 Date Time Qualifier PIC X(3) ID 3--3

173 2100 DTM 1DTM Statement From or To Date 2 2100

N/U by Medicare171 2100 REFREF Rendering Provider Identification 10 2100 N/A

5022REF02 Other Claim Related ID/(Medical Record #) PIC X(50) AN 1--50

19 3EA, 6P, 28, F818 N/U by Part B

REF01 Reference ID Qualifier/(Medical Record ID #) PIC X(3) ID 2--3

169 2100 REF 1REF Other Claim-Related Identification 5 2100

18315MOA09 Nonpayable Professional Comp Amt

05 Nonpayable Professional Comp Amt - Group PIC X(18)05 Nonpayable Professional Comp Amt REDEF REDEFINESNonpayable Professional Comp Amt -Group10 Nonpayable Professional Comp Amt PICS9(8)V9910 Nonpayable Professional Comp Amt Filler PIC X(8)

R 1--18

297 18

50

MOA08 Claim ESRD Payment Amount 05 Claim ESRD Payment Amount - G PIC

R 1--18

247MOA07 CLAIM PAYMENT REMARK CD X(5) PIC X(50) AN 1--50

197 50

Length

Record Repeat

Comment

MOA06 CLAIM PAYMENT REMARK CD X(5) PIC X(50) AN 1--50

Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values





147 50

97 50



47 5029 18

N/U for Part B


N/U for Part B

MOA02 Claim HCPCS Payable Amount

05 Claim HCPCS Payable Amount - Group PIC X(18)05 Claim HCPCS Payable Amount REDEF REDEFINESClaim HCPCS Payable Amount - Group10 Claim HCPCS Payable Amount PICS9(8)V9910 Claim HCPCS Payable Amount Filler PIC X(8)

R 1--18

19 10MOA01 Reimbursement Rate

05 Reimbursement Rate - Group PIC X(10)05 Reimbursement Rate REDEF REDEFINESReimbursement Rate -Group10 Reimbursement Rate PIC S9(4)V999910 Reimbursement Rate Filler PIC X(2)

R 1--10


11


N/U

SR

RN/U

SR

S

R

R

S

S

S

S

N/U

Usage Req

SR

RN/U

SR

RN/U

SR

R

R

S

S

S

Usage Req

S

N/U

N/U

R

RS 48113SVC04 NUBC Revenue Code PIC X(48) AN 1--48

95 18

18

SVC03 Line Item Provider Payment 05 Line Item Provider Payment - Gro p PIC

R 1--18

77SVC02 Line Item Charge Amount 05 Line Item Charge Amount - Gro p PIC X(18)

R 1--18

-01-8 Product/Service ID AN 1--48

-01-7 Procedure Code Description AN 1--80

75 2

Length

Record Repeat

Comment

-01-6 Procedure Modifier PIC X(2) AN 2--2

Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values





273-01-5 Procedure Modifier PIC X(2) AN 2--2

71 2

2



21 48

2

-01-2 Adjudicated Procedure Code PIC X(48) AN 1--48

19-01-1 Product or Service ID Qualifier PIC X(2) ID 2--2 HC, HP, N4, NU

18 1SVC01 Composite Medical Procedure Identifier

186 2110 SVC 1SVC Service Payment Information 1 2110 999

-QTY04

N/U15

QTY03- Composite Unit of Measure AN 1-3021QTY02 Claim Supplemental Information Quantity 05 Claim Supplemental

Information Q antit Gro p R 1--15

19 2CA, CD, LA, OU ZK, ZL, ZM, ZN, ZO18 14

QTY01 Quantity Qualifier PIC X(2) ID 2--2

184 2100 QTY 1QTY Claim Supplemental Infor Quantity 14 2100

AMT03 Credit/Debit Flag Code ID 1-122 18

3

AMT02 Claim Supplemental Information Amt

05 Claim Supplemental Information Amt - Group PIC X(18)05 Claim Supplemental Information Amt REDEF REDEFINESClaim Supplemental Information Amt -Group10 Claim Supplemental Information Amt PIC S9(8)V9910 Claim Supplemental Information Amt Filler PIC X(8)

R 1--18

19AMT01 Amount Qualifier Code PIC X(3) ID 1--3 AU, DY, F5, I, NL, ZK, ZL, ZM, ZN, ZOAMT 1 18 13182 2100

Length

Record Repeat

Comment

AMT Claim Supplemental Information 13 2100

Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values






599 256

597 2

PER08 Communication # Extension PIC X(256) AN 1--256

EXPER07 Communication # Qualifier PIC X(2) ID 2--2

341 256

339 2

PER06 Claim Contact Communication#

PIC X(256) AN 1--256

EM,EX,FX,TEPER05 Communication # Qualifier PIC X(2) ID 2--2

83 256

81 2

PER04 Claim Contact Communication#

PIC X(256) AN 1--256

EM,FX,TEPER03 Communication # Qualifier PIC X(2) ID 2--2

21 60

19 2

PER02 Claim Contact Name PIC X(60) AN 1--60

CXPER01 Contact Function Code PIC X(2) ID 2--2PER 1 18 22100 179 2100PER Claim Contact Information 2

-DTM06

DTM03- Time TM 4-822 8CCYYMMDD

19 3

DTM02 Claim Received Date 05 Claim Received Date - Group PIC X(8)

DT 8--8

050DTM01 Date/Time Qualifier PIC X(3) ID 3--3DTM 1 18 12100 177 2100DTM Claim Received Date 1

-DTM06

DTM03- Time TM 4-8


12


SS

R

R

S

S

S

S

S

N/U

Usage Req

S

SR

RN/U

SR

R

R

S

Usage Req

S

SS

S

SS

S

SS

Usage Req

S

SS

S

S

SR

R

N/UREF03- Description AN 1--80

22 50

19 3 LU - required if the specific site of service

REF02 Reference Identification PIC X(50) AN 1--50

LU, 1S, APC, RBREF01 Reference ID Qualifier PIC X(3) ID 2--3REF 1 18 82110 204 2110REF Service Identification 8

234 15

216 18


R 1--15


R 1--18

211 5196 15


PIC X(15)R 1--15

178 18

Start Length

Record Repeat

Comment


R 1--18

Values Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop


835 TR3 5010A1




173 515


PIC X(15)R 1--15

140 18

5


R 1--18

135CAS11 Adjustment Reason Code PIC X(5) ID 1--5120 15

18


R 1--15


R 1--18

97 515


PIC X(15)R 1--15

64 18

Length

Record Repeat

Comment


R 1--18

Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values





59 5PIC X(5)CAS05 Adjustment Reason Code ID 1--5 S

44 15

18


R 1--15


R 1--18

21 5

2 Group Code CR has been deleted


19CAS01 Claim Adjustment Group Code PIC X(2) ID 1--2 CO,OA,PRCAS 1 18 99196 2110CAS Service Adjustment 99 2110

-DTM06

DTM03- Time TM 4--822 8CCYYMMDD

3

DTM02 Service Date 05 Service Date - Group PIC X(8)05 S i D t G REDEF

DT 8--8

19DTM01 Date Time Qualifier PIC X(3) ID 3--3 150, 151, 472DTM 1 18 2194 2110DTM Service Date 2 2110

314 15

Length

Record Repeat

Comment

SVC07 Original Units of Service Count 05 Original Units of Service Count Gro p PIC X(15)

R 1--15

Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values





Mediare will populate if received on the claim

-06-8 Product/Service ID AN 1--48

234 80

2

-06-7 Procedure Code Description PIC X(80) AN 1--80


230 2

2



226 2

48


178-06-2 Procedure Code PIC X(48) AN 1--48

176 2HC, HP, N4, NU-06-1 Product or Service ID Qualifier PIC X(2) ID 2--2

SVC06 Composite Medical Procedure Identifier161 15SVC05 Units of Service Paid Count 05 Units of Service Paid Count -

G PIC R 1--15


13


SR

R

N/U

Usage Req

SR

R

N/U

SR

R

N/U

SR

RN/U

S

SR

R

Usage Req

SR

RR

RS

RS

R

S 149 50

147 2Instruction to use TL - CR from OFM

-05-2 Provider Adjustment Identifier PIC X(50) AN 1--50

50, 51, 72, AP, B2, B3,BD, BN, C5, CS, CV,

-05-1 Adjustment Reason Code

PIC X(2)ID 2--2

129 18PLB05 Adjustment IdentifierPLB04 Provider Adjustment Amount

05 Provider Adjustment Amount - Group PIC X(18)05 Provider Adjustment Amount REDEF REDEFINESProvider Adjustment Amount - Group10 Provider Adjustment Amount PIC S9(8)V9910 Provider Adjustment Amount Filler PIC X(8)

R 1--18

79 5077 2

Instruction to use TL - CR from OFM

-03-2 Provider Adjustment Identifier PIC X(50) AN 1--50

50, 51, 72, AP, B2, B3,BD, BN, C5, CS, CV,DM E3 FB GO HM

-03-1 Adjustment Reason CodePIC X(2)

ID 2--2

69 8PLB03 Adjustment Identifier

CCYYMMDD

Legacy in case of VA pricing

PLB02 Fiscal Period Date05 Fiscal Period Date - Group PIC X(8) DT 8--8

19 50NPI1 18 1

PLB-01 Provider Identifier PIC X(50) AN 1--50

217 PLBPLB Provider Level Adjustment >1 ------- 1

Start Length

Record Repeat

CommentValues Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop


835 TR3 5010A1




22 30

3

LQ02 Remark Code X(5) PIC X(30) AN 1--30

19LQ01 Code List Qualifier Code PIC X(3) ID 1--3 HELQ 1 18 99215 2110LQ Health Care Remarks Codes 99 2110

Not used by MedicareQTYN/A 213 2110QTY Service Supplemental Quantity 6 2110

18AMT03 Credit/Debit Flag Code ID 1--1

22AMT02 Service Supplemental Amount 05 Service Supplemental Amount - Gro p PIC X(18)

R 1--18

19 3B6, KH, ZK, ZL, ZM, ZN, ZO18 12

AMT01 Amount Qualifier Code PIC X(3) ID 1--3

211 2110 AMT 1AMT Service Supplemental Amount 9 2110

-REF04

50 NCD/LCD code


22REF02 Reference Identification PIC X(50) AN 1--50

19 30K18 5

REF01 Reference ID Qualifier PIC X(3) ID 2--3

209 2110 REF 1REF Health Care Policy Identification 5 2110

-REF04

50


22REF02 Rendering Provider ID PIC X(50) AN 1--50

19 3HPI, SY, TJ, 1C, 1G18 10

REF01 Reference ID Qualifier PIC X(3) ID 2--3

207 2110 REF 1REF Rendering Provider Information 10 2110

Comment

-REF04



Values Page #

Loop ID

Loop Seq

Element Identifier

COBOL PIC

ID Min/Max Loop






22 50

19 3

REF02 Line Item Control Number PIC X(50) AN 1--50

6RREF01 Reference ID Qualifier PIC X(3) ID 2--3REF 1 18 12110 206 2110REF Line Item Control Number 1

-REF04


14


Usage Req

SS

RS

SS

RS

SS

Usage Req

RS

SS

RS

S

RR

R

R

Usage Req

R

R

R

R 19 5Total functional groups (GS-GE pairs)1 18 1

IEA01 # Included Functional Groups PIC 9(5) N0 1-5

IEAIEA Interchange Control Trailer 1 ----

25 9Same Value as in GS06GE02 Group Control # PIC 9(9) N0 1-9

19 6Total transaction sets (ST-SE pairs)

Start Length

Record Repeat

Comment

GE01 # Transaction Sets Included PIC 9(6) N0 1-6

Values Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop


835 TR3 5010A1




GE 1 18 1GE Functional Group Trailer 1 ---

29 9=ST02

10

SE02 Transition Set Control # PIC X(9) AN 4--9

19SE01 Transition Segment Count PIC 9(10) N0 1--10SE 1 18 11 228SE Transaction Set Trailer 1 ----

479 18

50

PLB14 Provider Adjustment Amount 05 Provider Adjustment Amount - Gro p PIC X(18)

R 1--18

429


-13-2 Provider Adjustment Identifier PIC X(50) AN 1--50427 2

50, 51, 72, AP, B2, B3,BD, BN, C5, CS, CV,DM, E3, FB, GO, HM,IP, IS, IR, J1, L3, L6,

LE, LS, OA, OB, PI, PL, RA, RE, SL, TL, WO, WU-13-1 Adjustment Reason Code

PIC X(2)

ID 2--2

PLB13 Adjustment Identifier409 18

50

PLB12 Provider Adjustment Amount 05 Provider Adjustment Amount - G PIC X(18)

R 1--18

359




LE, LS, OA, OB, PI, PL, RA, RE, SL, TL, WO, WU

Length

Record Repeat

Comment


PIC X(2)

ID 2--2

Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values






50


R 1--18

289






PIC X(2)

ID 2--2


50


R 1--18

219






PIC X(2)

ID 2--2


Length

Record Repeat

Comment

PLB06 Provider Adjustment Amount 05 Provider Adjustment Amount - G PIC X(18)

R 1--18

Page #

Loop ID


Element Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values






15


R 24 9Same value as in ISA13IEA02 Interchange Control # PIC 9(9) N0 9-9

Documents

835 Flat File - 5010A1 UPDATED 2/27/2018 · 835 Flat File - 5010A1 UPDATED 2/27/2018 1 Legend: Changed field highlighted in yellow Usa 4 405 R R R R R R R