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Stedi maintains this guide based on public documentation from CGS Medicare. Contact CGS Medicare for official EDI specifications. To report any errors in this guide, please contact us. X12 835 Health Care Claim Payment/Advice (X221A1) X12 Release 5010 Revised November 17, 2023 Go to Stedi Network This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Payment/Advice Transaction Set (835) for use within the context of the Electronic Data Interchange (EDI) environment. This transaction set can be used to make a payment, send an Explanation of Benefits (EOB) remittance advice, or make a payment and send an EOB remittance advice only from a health insurer to a health care provider either directly or via a financial institution. Delimiters ~ Segment * Element > Component ^ Repetition View the latest version of this implementation guide as an interactive webpage https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice- x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 POWERED BY Build EDI implementation guides at stedi.com 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 1/125 Overview ISA - Interchange Control Header Max use 1 Required GS - Functional Group Header Max use 1 Required Heading ST 0100 Transaction Set Header Max use 1 Required BPR 0200 Financial Information Max use 1 Required TRN 0400 Reassociation Trace Number Max use 1 Required CUR 0500 Foreign Currency Information Max use 1 Optional REF 0600 Receiver Identification Max use 1 Optional REF 0600 Version Identification Max use 1 Optional DTM 0700 Production Date Max use 1 Optional Payer Identification Loop N1 0800 Payer Identification Max use 1 Required N3 1000 Payer Address Max use 1 Required N4 1100 Payer City, State, ZIP Code Max use 1 Required REF 1200 Additional Payer Identification Max use 4 Optional PER 1300 Payer Business Contact Information Max use 1 Optional PER 1300 Payer Technical Contact Information Max use 1 Required PER 1300 Payer WEB Site Max use 1 Optional Payee Identification Loop N1 0800 Payee Identification Max use 1 Required N3 1000 Payee Address Max use 1 Optional N4 1100 Payee City, State, ZIP Code Max use 1 Optional REF 1200 Payee Additional Identification Max use 1 Optional RDM 1400 Remittance Delivery Method Max use 1 Optional Detail Header Number Loop LX 0030 Header Number Max use 1 Required TS3 0050 Provider Summary Information Max use 1 Optional TS2 0070 Provider Supplemental Summary Information Max use 1 Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 2/125 Claim Payment Information Loop CLP 0100 Claim Payment Information Max use 1 Required CAS 0200 Claim Adjustment Max use 99 Optional NM1 0300 Corrected Patient/Insured Name Max use 1 Optional NM1 0300 Corrected Priority Payer Name Max use 1 Optional NM1 0300 Crossover Carrier Name Max use 1 Optional NM1 0300 Insured or Subscriber Max use 1 Optional NM1 0300 Other Subscriber Name Max use 1 Optional NM1 0300 Patient Name Max use 1 Required NM1 0300 Service Provider Name Max use 1 Optional MIA 0330 Inpatient Adjudication Information Max use 1 Optional MOA 0350 Outpatient Adjudication Information Max use 1 Optional REF 0400 Other Claim Related Identification Max use 5 Optional DTM 0500 Claim Received Date Max use 1 Optional DTM 0500 Coverage Expiration Date Max use 1 Optional DTM 0500 Statement From or To Date Max use 2 Optional PER 0600 Claim Contact Information Max use 2 Optional AMT 0620 Claim Supplemental Information Max use 13 Optional QTY 0640 Claim Supplemental Information Quantity Max use 14 Optional Service Payment Information Loop SVC 0700 Service Payment Information Max use 1 Required DTM 0800 Service Date Max use 2 Optional CAS 0900 Service Adjustment Max use 99 Optional REF 1000 HealthCare Policy Identification Max use 5 Optional REF 1000 Line Item Control Number Max use 1 Optional REF 1000 Rendering Provider Information Max use 10 Optional REF 1000 Service Identification Max use 8 Optional AMT 1100 Service Supplemental Amount Max use 9 Optional QTY 1200 Service Supplemental Quantity Max use 6 Optional LQ 1300 Health Care Remark Codes Max use 99 Optional Summary 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 3/125 PLB 0100 Provider Adjustment Max use 1 Optional SE 0200 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 4/125 ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange- related control segments Example ISA00 00 XXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXX2501301107^0050100000000 0XX>~ Max use 1 Required ISA-01 I01 Authorization Information Qualifier Identifier (ID) Required Code identifying the type of information in the Authorization Information 00 No Authorization Information Present (No Meaningful Information in I02) ISA-02 I02 Authorization Information Min 10 Max 10 String (AN) Required Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01) ISA-03 I03 Security Information Qualifier Identifier (ID) Required Code identifying the type of information in the Security Information 00 No Security Information Present (No Meaningful Information in I04) ISA-04 I04 Security Information Min 10 Max 10 String (AN) Required This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03) ISA-05 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-06 I06 Interchange Sender ID Min 15 Max 15 String (AN) Required Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element ISA-07 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 5/125 Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-08 I07 Interchange Receiver ID Min 15 Max 15 String (AN) Required Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them ISA-09 I08 Interchange Date YYMMDD format Date (DT) Required Date of the interchange ISA-10 I09 Interchange Time HHMM format Time (TM) Required Time of the interchange ISA-11 I65 Repetition Separator Min 1 Max 1 String (AN) Required Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator ^ Repetition Separator ISA-12 I11 Interchange Control Version Number Identifier (ID) Required Code specifying the version number of the interchange control segments 00501 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003 ISA-13 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender ISA-14 I13 Acknowledgment Requested Min 1 Max 1 Identifier (ID) Required Code indicating sender's request for an interchange acknowledgment 0 No Interchange Acknowledgment Requested 1 Interchange Acknowledgment Requested (TA1) ISA-15 I14 Interchange Usage Indicator Min 1 Max 1 Identifier (ID) Required Code indicating whether data enclosed by this interchange envelope is test, production or information I Information 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 6/125 P Production Data T Test Data ISA-16 I15 Component Element Separator Min 1 Max 1 String (AN) Required Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator > Component Element Separator 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 7/125 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GSHPXXXXXXXXXXXXXX20250130101100X005010X2 21A1~ Max use 1 Required GS-01 479 Functional Identifier Code Identifier (ID) Required Code identifying a group of application related transaction sets HP Health Care Claim Payment/Advice (835) GS-02 142 Application Sender's Code Min 2 Max 15 String (AN) Required Code identifying party sending transmission; codes agreed to by trading partners GS-03 124 Application Receiver's Code Min 2 Max 15 String (AN) Required Code identifying party receiving transmission; codes agreed to by trading partners GS-04 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year GS-05 337 Time HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time (TM) Required 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) GS-06 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480 T Transportation Data Coordinating Committee (TDCC) X Accredited Standards Committee X12 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 8/125 GS-08 480 Version / Release / Industry Identifier Code String (AN) Required 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 005010X221A1 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 9/125 Heading ST 0100 Heading > ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST8350001~ Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) Required Code uniquely identifying a Transaction Set The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set). Usage notes The only valid value within this transaction set for ST01 is 835. 835 Health Care Claim Payment/Advice ST-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Start with a number, for example 0001, and increment from there. This number must be unique within a specific group and interchange, but it can be repeated in other groups and interchanges. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 10/125 BPR 0200 Heading > BPR Financial Information To indicate the beginning of a Payment Order/Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and/or information from payer to payee to occur Usage notes Use the BPR to address a single payment to a single payee. A payee may represent a single provider, a provider group, or multiple providers in a chain. The BPR contains mandatory information, even when it is not being used to move funds electronically. Example BPRI00CACHCTX01XXXXXXDAXXXXXXXXXXXXXXX XXXXXXX01XXXXXXSGXXX20250130~ If either Depository Financial Institution (DFI) Identification Number Qualifier	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
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) GS-06 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480 T Transportation Data Coordinating Committee (TDCC) X Accredited Standards Committee X12 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 8/125 GS-08 480 Version / Release / Industry Identifier Code String (AN) Required 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 005010X221A1 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 9/125 Heading ST 0100 Heading > ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST8350001~ Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) Required Code uniquely identifying a Transaction Set The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set). Usage notes The only valid value within this transaction set for ST01 is 835. 835 Health Care Claim Payment/Advice ST-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Start with a number, for example 0001, and increment from there. This number must be unique within a specific group and interchange, but it can be repeated in other groups and interchanges. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 10/125 BPR 0200 Heading > BPR Financial Information To indicate the beginning of a Payment Order/Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and/or information from payer to payee to occur Usage notes Use the BPR to address a single payment to a single payee. A payee may represent a single provider, a provider group, or multiple providers in a chain. The BPR contains mandatory information, even when it is not being used to move funds electronically. Example BPRI00CACHCTX01XXXXXXDAXXXXXXXXXXXXXXX XXXXXXX01XXXXXXSGXXX20250130~ If either Depository Financial Institution (DFI) Identification Number Qualifier (BPR-06) or Sender DFI Identifier (BPR-07) is present, then the other is required If Account Number Qualifier (BPR-08) is present, then Sender Bank Account Number (BPR-09) is required If either Depository Financial Institution (DFI) Identification Number Qualifier (BPR-12) or Receiver or Provider Bank ID Number (BPR-13) is present, then the other is required If Account Number Qualifier (BPR-14) is present, then Receiver or Provider Account Number (BPR-15) is required Max use 1 Required BPR-01 305 Transaction Handling Code Identifier (ID) Required Code designating the action to be taken by all parties C Payment Accompanies Remittance Advice Use this code to instruct your third party processor to move both funds and remittance detail together through the banking system. D Make Payment Only Use this code to instruct your third party processor to move only funds through the banking system and to ignore any remittance information. H Notification Only Use this code when the actual provider payment (BPR02) is zero and the transaction is not being used for Prenotification of Future Transfers. This indicates remittance information without any associated payment. I Remittance Information Only Use this code to indicate to the payee that the remittance detail is moving separately from the payment. P Prenotification of Future Transfers This code is used only by the payer and the banking system to initially validate account numbers before beginning an EFT relationship. Contact your VAB for additional information. U Split Payment and Remittance Use this code to instruct the third party processor to split the payment and remittance detail, and send each on a separate path. X Handling Party's Option to Split Payment and Remittance Use this code to instruct the third party processor to move the payment and remittance detail, either together or separately, based upon end point requests or capabilities. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 11/125 BPR-02 782 Total Actual Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount BPR02 specifies the payment amount. Usage notes Use BPR02 for the total payment amount for this 835. The total payment amount for this 835 cannot exceed eleven characters, including decimals (99999999.99). Although the value can be zero, the 835 cannot be issued for less than zero dollars. Decimal elements 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). BPR-03 478 Credit or Debit Flag Code Identifier (ID) Required Code indicating whether amount is a credit or debit C Credit Use this code to indicate a credit to the provider's account and a debit to the payer's account, initiated by the payer. In the case of an EFT, no additional action is required of the provider. Also use this code when a check is issued for the payment. BPR-04 591 Payment Method Code Identifier (ID) Required Code identifying the method for the movement of payment instructions ACH Automated Clearing House (ACH) Use this code to move money electronically through the ACH, or to notify the provider that an ACH transfer was requested. When this code is used, see BPR05 through BPR15 for additional requirements. CHK Check Use this code to indicate that a check has been issued for payment. NON Non-Payment Data Use this code when the Transaction Handling Code (BPR01) is H, indicating that this is information only and no dollars are to be moved. BPR-05 812 Payment Format Code Identifier (ID) Optional Code identifying the payment format to be used CCP Cash Concentration/Disbursement plus Addenda (CCD+) (ACH) Use the CCD+ format to move money and up to 80 characters of data, enough to reassociate dollars and data when the dollars are sent through the ACH and the data is sent on a separate path. The addenda must contain a copy of the TRN segment. CTX Corporate Trade Exchange (CTX) (ACH) Use the CTX format to move dollars and data through the ACH. The CTX format can contain up to 9,999 addenda records of 80 characters each. The CTX encapsulates the complete 835 and all envelope segments. BPR-06 506 Depository Financial Institution (DFI) Identification Number Qualifier Optional Identifier (ID) Code identifying the type of identification number of Depository Financial Institution (DFI) 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 12/125 When using this transaction set to initiate a payment, all or some of BPR06 through BPR16 may be required, depending on the conventions of the specific financial channel being used. BPR06 and BPR07 relate to the originating depository financial institution (ODFI). Usage notes BPR06 through BPR09 relate to the originating financial institution and the originator's account (payer). 01 ABA Transit Routing Number Including Check Digits (9 digits) The ABA transit routing number is a unique number identifying every bank in the United States. BPR-07 507 Sender DFI Identifier Min 3 Max 12 String (AN) Optional Depository Financial Institution (DFI) identification number Usage notes Use this number for the identifying number of the financial institution sending the transaction into the applicable network. BPR-08 569 Account Number Qualifier Identifier (ID) Optional Code indicating the type of account BPR08 is a code identifying the type of bank account or other financial asset. Usage notes Use this code to identify the type of account in BPR09. DA Demand Deposit BPR-09 508 Sender Bank Account Number Min 1 Max 35 String (AN) Optional Account number assigned BPR09 is the account of the company originating the payment. This account may be debited or credited depending on the type of payment order. Usage notes Use this number for the originator's account number at the financial institution. BPR-10 509 Payer Identifier Min 10 Max 10 String (AN) Optional A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification. BPR10 shall be mutually established between the originating depository financial institution (ODFI) and the company originating the payment. BPR-11 510 Originating Company Supplemental Code Min 9 Max 9 String (AN) Optional A code defined between the originating company and the originating depository financial institution (ODFI) that uniquely identifies the company initiating the transfer instructions Usage notes 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 13/125 Use this code to further identify the payer by division or region. The element must be left justified and space filled to meet the minimum element size requirements. If used, this code must be identical to TRN04, excluding trailing spaces. BPR-12 506 Depository Financial Institution (DFI) Identification Number Qualifier Optional Identifier (ID) Code identifying the type of identification number of Depository Financial Institution (DFI) BPR12 and BPR13 relate to the receiving depository financial institution (RDFI). Usage notes BPR12 through BPR15 relate to the receiving financial institution and the receiver's account. 01 ABA Transit Routing Number Including Check Digits (9 digits) The ABA transit routing number is a unique number identifying every bank in the United States. BPR-13 507 Receiver or Provider Bank ID Number Min 3 Max 12 String (AN) Optional Depository Financial Institution (DFI) identification number Usage notes Use this number for the identifying number of the financial institution receiving the transaction from the applicable network. BPR-14 569 Account Number Qualifier Identifier (ID) Optional Code indicating the type of account BPR14 is a code identifying the type of bank account or other financial asset. Usage notes Use this code to identify the type of account in BPR15. DA Demand Deposit SG Savings BPR-15 508 Receiver or Provider Account Number Min 1 Max 35 String (AN) Optional Account number assigned BPR15 is the account number of the receiving company to be debited or credited with the payment order. Usage notes Use this number for the receiver's account number at the financial institution. BPR-16 373 Check Issue or EFT Effective Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year BPR16 is the date the originating company intends for the transaction to be settled (i.e., Payment Effective Date). 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 14/125 Usage notes Use this for the effective entry date. If BPR04 is ACH, this is the date that the money moves from the payer and is available to the payee. If BPR04 is CHK, this is the check issuance date. If BPR04 is FWT, this is the date that the payer anticipates the money to move. As long as the effective date is a business day, this is the settlement date. If BPR04 is `NON', enter the date of the 835. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 15/125 TRN 0400 Heading > TRN Reassociation Trace Number To uniquely identify a transaction to an application Usage notes This segment's purpose is to uniquely identify this transaction set and to aid in reassociating payments and remittances that have been separated. Example TRN1XXXXXXXXXXXXXXXXX~ Max use 1 Required TRN-01 481 Trace Type Code Identifier (ID) Required Code identifying which transaction is being referenced 1 Current Transaction Trace Numbers TRN-02 127 Check or EFT Trace Number Min 1 Max 50	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
the transfer instructions Usage notes 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 13/125 Use this code to further identify the payer by division or region. The element must be left justified and space filled to meet the minimum element size requirements. If used, this code must be identical to TRN04, excluding trailing spaces. BPR-12 506 Depository Financial Institution (DFI) Identification Number Qualifier Optional Identifier (ID) Code identifying the type of identification number of Depository Financial Institution (DFI) BPR12 and BPR13 relate to the receiving depository financial institution (RDFI). Usage notes BPR12 through BPR15 relate to the receiving financial institution and the receiver's account. 01 ABA Transit Routing Number Including Check Digits (9 digits) The ABA transit routing number is a unique number identifying every bank in the United States. BPR-13 507 Receiver or Provider Bank ID Number Min 3 Max 12 String (AN) Optional Depository Financial Institution (DFI) identification number Usage notes Use this number for the identifying number of the financial institution receiving the transaction from the applicable network. BPR-14 569 Account Number Qualifier Identifier (ID) Optional Code indicating the type of account BPR14 is a code identifying the type of bank account or other financial asset. Usage notes Use this code to identify the type of account in BPR15. DA Demand Deposit SG Savings BPR-15 508 Receiver or Provider Account Number Min 1 Max 35 String (AN) Optional Account number assigned BPR15 is the account number of the receiving company to be debited or credited with the payment order. Usage notes Use this number for the receiver's account number at the financial institution. BPR-16 373 Check Issue or EFT Effective Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year BPR16 is the date the originating company intends for the transaction to be settled (i.e., Payment Effective Date). 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 14/125 Usage notes Use this for the effective entry date. If BPR04 is ACH, this is the date that the money moves from the payer and is available to the payee. If BPR04 is CHK, this is the check issuance date. If BPR04 is FWT, this is the date that the payer anticipates the money to move. As long as the effective date is a business day, this is the settlement date. If BPR04 is `NON', enter the date of the 835. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 15/125 TRN 0400 Heading > TRN Reassociation Trace Number To uniquely identify a transaction to an application Usage notes This segment's purpose is to uniquely identify this transaction set and to aid in reassociating payments and remittances that have been separated. Example TRN1XXXXXXXXXXXXXXXXX~ Max use 1 Required TRN-01 481 Trace Type Code Identifier (ID) Required Code identifying which transaction is being referenced 1 Current Transaction Trace Numbers TRN-02 127 Check or EFT Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TRN02 provides unique identification for the transaction. Usage notes This number must be unique within the sender/receiver relationship. The number is assigned by the sender. If payment is made by check, this must be the check number. If payment is made by EFT, this must be the EFT reference number. If this is a non- payment 835, this must be a unique remittance advice identification number. See 1.10.2.3, Reassociation of Dollars and Data, for additional information. TRN-03 509 Payer Identifier Min 10 Max 10 String (AN) Required A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification. TRN03 identifies an organization. Usage notes This must be a 1 followed by the payer's EIN (or TIN). TRN-04 127 Originating Company Supplemental Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TRN04 identifies a further subdivision within the organization. Usage notes 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 16/125 If both TRN04 and BPR11 are used, they must be identical, excluding trailing spaces. Since BPR11 has a min/max value of 9/9, whenever both are used, this element is restricted to a maximum size of 9. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 17/125 CUR 0500 Heading > CUR Foreign Currency Information To specify the currency (dollars, pounds, francs, etc.) used in a transaction Usage notes When the CUR segment is not present, the currency of payment is defined as US dollars. Required when the payment is not being made in US dollars. If not required by this implementation guide, do not send. Example CURPRXXX~ Max use 1 Optional CUR-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer CUR-02 100 Currency Code Min 3 Max 3 Identifier (ID) Required Code (Standard ISO) for country in whose currency the charges are specified Usage notes This is the currency code for the payment currency. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 18/125 REF 0600 Heading > REF Receiver Identification To specify identifying information Usage notes This is the business identification information for the transaction receiver. This may be different than the EDI address or identifier of the receiver. This is the initial receiver of the transaction. This information must not be updated if the transaction is routed through multiple intermediaries, such as clearinghouses, before reaching the payee. Required when the receiver of the transaction is other than the payee (e.g., a clearinghouse or billing service). If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example REFEVXX~ Variants (all may be used) REF Version Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EV Receiver Identification Number REF-02 127 Receiver Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 19/125 REF 0600 Heading > REF Version Identification To specify identifying information Usage notes Update this reference number whenever a change in the version or release number affects the 835. (This is not the ANSI ASCX12 version number as reported in the GS segment.) Required when necessary to report the version number of the adjudication system that generated the claim payments in order for the payer to resolve customer service questions from the payee. If not required by this implementation guide, do not send. Example REFF2XX~ Variants (all may be used) REF Receiver Identification Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F2 Version Code - Local REF-02 127 Version Identification Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 20/125 DTM 0700 Heading > DTM Production Date To specify pertinent dates and times Usage notes If your adjudication cycle completed on Thursday and your 835 is produced on Saturday, you are required to populate this segment with Thursday's date. Required when the cut off date of the adjudication system remittance run is different from the date of the 835 as identified in the related GS04 element. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example DTM40520250130~ Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 405 Production DTM-02 373 Production Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes Report the end date for the adjudication production cycle for claims included in this 835. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 21/125 1000A Payer Identification Loop Max 1 Required Variants (all may be used) Payee Identification Loop N1 0800 Heading > Payer Identification Loop > N1 Payer Identification To identify a party by type of organization, name, and code Usage notes Use this N1 loop to provide the name/address information for the payer. The payer's secondary identifying reference number is provided in N104, if necessary. Example N1PRXXXXXVXXXXX~ If either Identification Code Qualifier (N1-03) or Payer Identifier (N1-04) is present, then the other is required Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer N1-02 93 Payer Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). N1-04 67 Payer Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 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. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 22/125 N3 1000 Heading > Payer Identification Loop > N3 Payer Address To specify the location of the named party Example N3XXXXXXX~ Max use 1 Required N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 23/125 N4 1100 Heading > Payer Identification Loop > N4 Payer City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXXXX~ Only one of Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Payer State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 24/125 REF 1200 Heading > Payer Identification Loop > REF Additional Payer Identification To specify identifying information Usage notes The ID available in the TRN and N1 segments must be used before using the REF segment. Required when additional payer identification numbers beyond those in the TRN and Payer N1 segments are needed. If not required by this implementation guide, may be sent at sender's discretion, but cannot be required by the receiver. Example REF2UXXXXX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number For Medicare carriers or intermediaries,	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
name N1-03 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). N1-04 67 Payer Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 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. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 22/125 N3 1000 Heading > Payer Identification Loop > N3 Payer Address To specify the location of the named party Example N3XXXXXXX~ Max use 1 Required N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 23/125 N4 1100 Heading > Payer Identification Loop > N4 Payer City, State, ZIP Code To specify the geographic place of the named party Example N4XXXXXXXXXXXXXXX~ Only one of Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Payer State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 24/125 REF 1200 Heading > Payer Identification Loop > REF Additional Payer Identification To specify identifying information Usage notes The ID available in the TRN and N1 segments must be used before using the REF segment. Required when additional payer identification numbers beyond those in the TRN and Payer N1 segments are needed. If not required by this implementation guide, may be sent at sender's discretion, but cannot be required by the receiver. Example REF2UXXXXX~ Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number For Medicare carriers or intermediaries, use this qualifier for the Medicare carrier or intermediary ID number. For Blue Cross and Blue Shield Plans, use this qualifier for the Blue Cross Blue Shield association plan code. REF-02 127 Additional Payer Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes CGS reference ID 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 25/125 PER 1300 Heading > Payer Identification Loop > PER Payer Business Contact Information To identify a person or office to whom administrative communications should be directed Usage notes When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800) 555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number. Required when there is a business contact area that would apply to this remittance and all the claims. If not required by this implementation guide, do not send. Example PERCXXXFXXXXXXFXXXXXEXXXXXX~ Variants (all may be used) PER Payer Technical Contact Information PER Payer WEB Site If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required If either Communication Number Qualifier (PER-05) or Payer Contact Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Payer Contact Name Min 1 Max 60 String (AN) Optional Free-form name Usage notes 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). PER-03 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 26/125 PER-04 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 27/125 PER 1300 Heading > Payer Identification Loop > PER Payer Technical Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required to report technical contact information for this remittance advice. Example PERBLXXURXXXXFXXXXXXXEMXX~ Variants (all may be used) PER Payer Business Contact Information PER Payer WEB Site If either Communication Number Qualifier (PER-03) or Payer Contact Communication Number (PER-04) is present, then the other is required If either Communication Number Qualifier (PER-05) or Payer Technical Contact Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Payer Contact Communication Number (PER-08) is present, then the other is required Max use >1 Required PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named BL Technical Department PER-02 93 Payer Technical Contact Name Min 1 Max 60 String (AN) Optional Free-form name Usage notes 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). PER-03 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail TE Telephone Recommended UR Uniform Resource Locator (URL) Use only when there is no central telephone number for the payer entity. PER-04 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 28/125 PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is theextension for the preceding communicationscontact number. FX Facsimile TE Telephone UR Uniform Resource Locator (URL) PER-06 364 Payer Technical Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension When used, the value following this code is theextension for the preceding communicationscontact number. FX Facsimile UR Uniform Resource Locator (URL) PER-08 364 Payer Contact Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 29/125 1000A Payer Identification Loop end PER 1300 Heading > Payer Identification Loop > PER Payer WEB Site To identify a person or office to whom administrative communications should be directed Usage notes Required when any 2110 loop Healthcare Policy REF Segment is used. If not required by this implementation guide, do not send. This is a direct link to the policy location of the un-secure website. Example PERICURXXXXX~ Variants (all may be used) PER Payer Business Contact Information PER Payer Technical Contact Information Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number UR Uniform Resource Locator (URL) PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable Usage notes This is the payer's WEB site URL where providers can find policy and other related information. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 30/125 1000B Payee Identification Loop Max 1 Required Variants (all may be used) Payer Identification Loop N1 0800 Heading > Payee Identification Loop > N1 Payee Identification To identify a party by type of organization, name, and code Usage notes Use this N1 loop to provide the name/address information of the payee. The identifying reference number is provided in N104. Example N1PEXXXXXXX~ Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PE Payee N1-02 93 Payee Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Required if provider is not mandated by NPI. For individual providers as payees, use this qualifier to represent the Social Security Number. XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). This only applies in cases of post payment recovery. See section 1.10.2.16 (Post Payment Recovery) for further information. XX Centers for Medicare and Medicaid Services National Provider Identifier This is REQUIRED when the National Provider Identifier is mandated for use and the payee is a covered health care provider under the mandate. N1-04 67 Payee Identification Code Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 31/125 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. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 32/125 N3 1000 Heading > Payee Identification Loop > N3 Payee Address To specify the location of the named party Usage notes 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. Example N3XXXXXXXXX~ Max use	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
this implementation guide, do not send. This is a direct link to the policy location of the un-secure website. Example PERICURXXXXX~ Variants (all may be used) PER Payer Business Contact Information PER Payer Technical Contact Information Max use 1 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number UR Uniform Resource Locator (URL) PER-04 364 Communication Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable Usage notes This is the payer's WEB site URL where providers can find policy and other related information. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 30/125 1000B Payee Identification Loop Max 1 Required Variants (all may be used) Payer Identification Loop N1 0800 Heading > Payee Identification Loop > N1 Payee Identification To identify a party by type of organization, name, and code Usage notes Use this N1 loop to provide the name/address information of the payee. The identifying reference number is provided in N104. Example N1PEXXXXXXX~ Max use 1 Required N1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PE Payee N1-02 93 Payee Name Min 1 Max 60 String (AN) Required Free-form name N1-03 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Required if provider is not mandated by NPI. For individual providers as payees, use this qualifier to represent the Social Security Number. XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). This only applies in cases of post payment recovery. See section 1.10.2.16 (Post Payment Recovery) for further information. XX Centers for Medicare and Medicaid Services National Provider Identifier This is REQUIRED when the National Provider Identifier is mandated for use and the payee is a covered health care provider under the mandate. N1-04 67 Payee Identification Code Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 31/125 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. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 32/125 N3 1000 Heading > Payee Identification Loop > N3 Payee Address To specify the location of the named party Usage notes 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. Example N3XXXXXXXXX~ Max use 1 Optional N3-01 166 Payee Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payee Address Line Min 1 Max 55 String (AN) Optional Address information 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 33/125 N4 1100 Heading > Payee Identification Loop > N4 Payee City, State, ZIP Code To specify the geographic place of the named party Usage notes 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. Example N4XXXXXXXXXXXXX~ Only one of Payee State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Payee City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Payee State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State/Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Payee Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 34/125 REF 1200 Heading > Payee Identification Loop > REF Payee Additional Identification To specify identifying information Usage notes Required when identification of the payee is dependent upon an identification number beyond that supplied in the N1 segment. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver. Example REFD3XXXXX~ Max use >1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number D3 National Council for Prescription Drug Programs Pharmacy Number PQ Payee Identification TJ Federal Taxpayer's Identification Number This information must be in the N1 segment unless the National Provider ID or the Health Plan Identifier (HPID) or Other Entity Identifier (OEID) was used in N104. 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. REF-02 127 Additional Payee Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 35/125 RDM 1400 Heading > Payee Identification Loop > RDM Remittance Delivery Method To identify remittance delivery when remittance is separate from payment Usage notes 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. Payer should coordinate this process with their Originating Depository Financial Institution (ODFI). Example RDMBMXXX~ Max use 1 Optional RDM-01 756 Report Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent BM By Mail When used, RDM02 must be used. When BM is used, the remittance information will be mailed to the payee at the address identified in this 1000B loop. EM E-Mail Use with encrypted e-mail. FT File Transfer Use with FTP communications. OL On-Line Use with secured hosted or other electronic delivery. RDM-02 93 Name Min 1 Max 60 String (AN) Optional Free-form name RDM02 is used to contain the name of a third party processor if needed, who would be the first recipient of the remittance. Usage notes 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. RDM-03 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable RDM03 contains the operative communication number for the delivery method specified in RDM01 (i.e. fax phone number and mail address). Usage notes 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 36/125 1000B Payee Identification Loop end Heading end Contains URL web address or e-mail address. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 37/125 Detail 2000 Header Number Loop Max >1 Optional LX 0030 Detail > Header Number Loop > LX Header Number To reference a line number in a transaction set Usage notes Required when claim/service information is being provided in the transaction. If not required by this implementation guide, do not send. The purpose of LX01 is to provide an identification of a particular grouping of claims for sorting purposes. In the event that claim/service information must be sorted, the LX segment must precede each series of claim level and service level segments. This number is intended to be unique within each transaction. Example LX0~ Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set Usage notes Medicare will send “1” for Assigned or “0” for NonAssigned. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 38/125 TS3 0050 Detail > Header Number Loop > TS3 Provider Summary Information To supply provider-level control information Usage notes TS301 identifies the subsidiary provider. The remaining mandatory elements (TS302 through TS305) must be valid with appropriate data, as defined by the TS3 segment. Only Medicare Part A uses data elements TS313, TS315, TS317, TS318 and TS320 through TS324. Each monetary amount element is for that provider for this facility type code for loop 2000. Required for Medicare Part A or when payers and payees outside the Medicare Part A community need to identify provider subsidiaries whose remittance information is contained in the 835 transactions transmitted to a single provider entity [i.e., the corporate office of a hospital chain]. If not required by this implementation guide, do not send. Example TS3XX202501300000000000000*****0000000000 00000000000000*0000000000000000*00000000000 00000000000000000000000*00~ Max use 1 Optional TS3-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TS301 is the provider number. Usage notes This is the provider number. TS3-02 1331 Facility Type Code Min 1 Max 2 String (AN) Required Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. Usage notes When reporting a TS3 segment for professional claims and the claims are not all for the same place of service, report a place of service of 11 (Office) as the default value. When reporting a TS3 segment for pharmaceutical claims and the claims are not all for the same place of service, report a place of service of 99 (Other unlisted facility) as the default value. TS3-03 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year TS303 is the last day of the provider's fiscal year. Usage notes 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 39/125 Use this date for the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known, use December 31st of the current year. TS3-04 380 Total Claim Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity TS304 is the total number of claims. Usage notes This is the total number of claims. TS3-05 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount TS305 is the total of reported charges. Usage notes This is the total reported charges for all claims. Decimal elements 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). This applies to all 782 elements. TS3-13 782 Total MSP Payer Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS313 is the total Medicare Secondary Payer (MSP) primary payer amount. Usage notes See TR3 note 3. TS3-15 782 Total Non-Lab Charge Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS315 is the summary of non-lab charges. Usage notes See TR3 note 3. TS3-17 782	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
mandatory elements (TS302 through TS305) must be valid with appropriate data, as defined by the TS3 segment. Only Medicare Part A uses data elements TS313, TS315, TS317, TS318 and TS320 through TS324. Each monetary amount element is for that provider for this facility type code for loop 2000. Required for Medicare Part A or when payers and payees outside the Medicare Part A community need to identify provider subsidiaries whose remittance information is contained in the 835 transactions transmitted to a single provider entity [i.e., the corporate office of a hospital chain]. If not required by this implementation guide, do not send. Example TS3XX202501300000000000000*****0000000000 00000000000000*0000000000000000*00000000000 0000000000000000000000000~ Max use 1 Optional TS3-01 127 Provider Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier TS301 is the provider number. Usage notes This is the provider number. TS3-02 1331 Facility Type Code Min 1 Max 2 String (AN) Required Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. Usage notes When reporting a TS3 segment for professional claims and the claims are not all for the same place of service, report a place of service of 11 (Office) as the default value. When reporting a TS3 segment for pharmaceutical claims and the claims are not all for the same place of service, report a place of service of 99 (Other unlisted facility) as the default value. TS3-03 373 Fiscal Period Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year TS303 is the last day of the provider's fiscal year. Usage notes 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 39/125 Use this date for the last day of the provider's fiscal year. If the end of the provider's fiscal year is not known, use December 31st of the current year. TS3-04 380 Total Claim Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity TS304 is the total number of claims. Usage notes This is the total number of claims. TS3-05 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount TS305 is the total of reported charges. Usage notes This is the total reported charges for all claims. Decimal elements 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). This applies to all 782 elements. TS3-13 782 Total MSP Payer Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS313 is the total Medicare Secondary Payer (MSP) primary payer amount. Usage notes See TR3 note 3. TS3-15 782 Total Non-Lab Charge Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS315 is the summary of non-lab charges. Usage notes See TR3 note 3. TS3-17 782 Total HCPCS Reported Charge Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS317 is the Health Care Financing Administration Common Procedural Coding System (HCPCS) reported charges. Usage notes See TR3 note 3. TS3-18 782 Total HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 40/125 Monetary amount TS318 is the total Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes See TR3 note 3. TS3-20 782 Total Professional Component Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS320 is the total professional component amount. Usage notes The professional component amount must also be reported in the CAS segment with a Claim Adjustment Reason Code value of 89. See TR3 note 3. TS3-21 782 Total MSP Patient Liability Met Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS321 is the total Medicare Secondary Payer (MSP) patient liability met. Usage notes See TR3 note 3. TS3-22 782 Total Patient Reimbursement Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS322 is the total patient reimbursement. Usage notes See TR3 note 3. TS3-23 380 Total PIP Claim Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS323 is the total periodic interim payment (PIP) number of claims. Usage notes See TR3 note 3. TS3-24 782 Total PIP Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS324 is total periodic interim payment (PIP) adjustment. Usage notes 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 41/125 See TR3 note 3. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 42/125 TS2 0070 Detail > Header Number Loop > TS2 Provider Supplemental Summary Information To provide supplemental summary control information by provider fiscal year and bill type Usage notes This segment provides summary information specific to an iteration of the LX loop (Table 2). Each element represents the total value for the provider/bill type combination in this loop 2000 iteration. Required for Medicare Part A. If not required by this implementation guide, do not send. Example TS20000000000000000000000000000000000000000 00000000000000000000000000000000000000000000 0000000000000000000000000000000000000000000 000000000000000~ Max use 1 Optional TS2-01 782 Total DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS201 is the total diagnosis related group (DRG) amount. Usage notes This includes: operating federal-specific amount, operating hospital-specific amount, operating Indirect Medical Education amount, and operating Disproportionate Share Hospital amount. It does not include any operating outlier amount. See TR3 note 2. TS2-02 782 Total Federal Specific Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS202 is the total federal specific amount. Usage notes See TR3 note 2. TS2-03 782 Total Hospital Specific Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS203 is the total hospital specific amount. Usage notes See TR3 note 2. TS2-04 782 Total Disproportionate Share Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS204 is the total disproportionate share amount. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 43/125 Usage notes See TR3 note 2. TS2-05 782 Total Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS205 is the total capital amount. Usage notes This includes: capital federal-specfic amount, hospital federal-specfic amount, hold harmless amount, Indirect Medical Education amount, Disproportionate Share Hospital amount, and the exception amount. It does not include any capital outlier amount. See TR3 note 2. TS2-06 782 Total Indirect Medical Education Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS206 is the total indirect medical education amount. Usage notes See TR3 note 2. TS2-07 380 Total Outlier Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS207 is the total number of outlier days. Usage notes See TR3 note 2. TS2-08 782 Total Day Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS208 is the total day outlier amount. Usage notes See TR3 note 2. TS2-09 782 Total Cost Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS209 is the total cost outlier amount. Usage notes See TR3 note 2. TS2-10 380 Average DRG Length of Stay Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 44/125 TS210 is the diagnosis related group (DRG) average length of stay. Usage notes See TR3 note 2. TS2-11 380 Total Discharge Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS211 is the total number of discharges. Usage notes This is the discharge count produced by PPS PRICER SOFTWARE. See TR3 note 2. TS2-12 380 Total Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS212 is the total number of cost report days. Usage notes See TR3 note 2. TS2-13 380 Total Covered Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS213 is the total number of covered days. Usage notes See TR3 note 2. TS2-14 380 Total Noncovered Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity TS214 is total number of non-covered days. Usage notes See TR3 note 2. TS2-15 782 Total MSP Pass-Through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS215 is the total Medicare Secondary Payer (MSP) pass- through amount calculated for a non-Medicare payer. Usage notes See TR3 note 2. TS2-16 380 Average DRG weight Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 45/125 Numeric value of quantity TS216 is the average diagnosis-related group (DRG) weight. Usage notes See TR3 note 2. TS2-17 782 Total PPS Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS217 is the total prospective payment system (PPS) capital, federal-specific portion, diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. TS2-18 782 Total PPS Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS218 is the total prospective payment system (PPS) capital, hospital-specific portion, diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. TS2-19 782 Total PPS DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS219 is the total prospective payment system (PPS) disproportionate share, hospital diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 46/125 2100 Claim Payment Information Loop Max >1 Required CLP 0100 Detail > Header Number Loop > Claim Payment Information Loop > CLP Claim Payment Information To supply information common to all services of a claim Usage notes For CLP segment occurrence limitations, see section 1.3.2, Other Usage Limitations. Example CLPXXX2000000000000000000000000012XXXX XXXXX0*0~ Max use 1 Required CLP-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment Usage notes Use this number for the patient control number assigned by the provider. If the patient control number is not present on the incoming claim, enter a single zero. The value in CLP01 must be identical to any value received as a Claim Submitter's Identifier on the original claim (CLM01 of the ANSI ASC X12 837, if applicable). This data element is the primary key for posting the remittance information into the provider's database. In the case of pharmacy claims, this is the prescription reference number (field 402-02 in the NCPDP 5.1 format). CLP-02 1029 Claim Status Code Identifier (ID) Required Code identifying the status of an entire claim as assigned by the payor, claim review organization or repricing organization Usage notes To determine the full claim status reference Claim adjustment reason codes in the CAS segment in conjunction with this claim status code. 1 Processed as Primary Use this code if the claim was adjudicated by the current payer as primary regardless of whether any part of the claim was paid. 2 Processed as Secondary Use this code if the claim was adjudicated by the current payer as secondary regardless of whether any part of the claim was paid. 3 Processed as Tertiary Use this code if the claim was adjudicated by the current payer as tertiary (or subsequent) regardless of whether any part of the claim was paid. 4 Denied Usage of this code would apply if the Patient/Subscriber is not recognized, and the claim was not forwarded to another payer. 19 Processed as Primary, Forwarded to Additional Payer(s) When this code is used, the Crossover Carrier Name NM1 segment is required. 20 Processed as Secondary, Forwarded to Additional Payer(s) 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 47/125 When this code is used, the Crossover Carrier Name NM1 segment is required. 21 Processed as Tertiary, Forwarded to Additional Payer(s)	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
system (PPS) capital, federal-specific portion, diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. TS2-18 782 Total PPS Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS218 is the total prospective payment system (PPS) capital, hospital-specific portion, diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. TS2-19 782 Total PPS DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount TS219 is the total prospective payment system (PPS) disproportionate share, hospital diagnosis-related group (DRG) amount. Usage notes See TR3 note 2. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 46/125 2100 Claim Payment Information Loop Max >1 Required CLP 0100 Detail > Header Number Loop > Claim Payment Information Loop > CLP Claim Payment Information To supply information common to all services of a claim Usage notes For CLP segment occurrence limitations, see section 1.3.2, Other Usage Limitations. Example CLPXXX2000000000000000000000000012XXXX XXXXX00~ Max use 1 Required CLP-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment Usage notes Use this number for the patient control number assigned by the provider. If the patient control number is not present on the incoming claim, enter a single zero. The value in CLP01 must be identical to any value received as a Claim Submitter's Identifier on the original claim (CLM01 of the ANSI ASC X12 837, if applicable). This data element is the primary key for posting the remittance information into the provider's database. In the case of pharmacy claims, this is the prescription reference number (field 402-02 in the NCPDP 5.1 format). CLP-02 1029 Claim Status Code Identifier (ID) Required Code identifying the status of an entire claim as assigned by the payor, claim review organization or repricing organization Usage notes To determine the full claim status reference Claim adjustment reason codes in the CAS segment in conjunction with this claim status code. 1 Processed as Primary Use this code if the claim was adjudicated by the current payer as primary regardless of whether any part of the claim was paid. 2 Processed as Secondary Use this code if the claim was adjudicated by the current payer as secondary regardless of whether any part of the claim was paid. 3 Processed as Tertiary Use this code if the claim was adjudicated by the current payer as tertiary (or subsequent) regardless of whether any part of the claim was paid. 4 Denied Usage of this code would apply if the Patient/Subscriber is not recognized, and the claim was not forwarded to another payer. 19 Processed as Primary, Forwarded to Additional Payer(s) When this code is used, the Crossover Carrier Name NM1 segment is required. 20 Processed as Secondary, Forwarded to Additional Payer(s) 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 47/125 When this code is used, the Crossover Carrier Name NM1 segment is required. 21 Processed as Tertiary, Forwarded to Additional Payer(s) When this code is used, the Crossover Carrier Name NM1 segment is required. 22 Reversal of Previous Payment See section 1.10.2.8 for usage information. 23 Not Our Claim, Forwarded to Additional Payer(s) Usage of this code would apply if the patient/subscriber is not recognized, the claim was not adjudicated by the payer, but other payers are known and the claim has been forwarded to another payer. When this code is used, the Crossover Carrier Name NM1 segment is required. CLP-03 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLP03 is the amount of submitted charges this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. Use this monetary amount for the submitted charges for this claim. The amount can be positive, zero or negative. An example of a situation with a negative charge is a reversal claim. See section 1.10.2.8 for additional information. Decimal elements 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). This applies to all subsequent 782 elements. CLP-04 782 Claim Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CLP04 is the amount paid this claim. Usage notes See 1.10.2.1, Balancing, in this implementation guide for additional information. See section 1.10.2.9 for information about interest considerations. Use this monetary amount for the amount paid for this claim. It can be positive, zero or negative, but the value in BPR02 may not be negative. CLP-05 782 Patient Responsibility Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CLP05 is the patient responsibility amount. Usage notes Amounts in CLP05 must have supporting adjustments reflected in CAS segments at the 2100 (CLP) or 2110 (SVC) loop level with a Claim Adjustment Group (CAS01) code of PR (Patient Responsibility). Use this monetary amount for the payer's statement of the patient responsibility amount for this claim, which can include such items as deductible, non-covered services, co-pay and co-insurance. This is not used for reversals. See section 1.10.2.8, Reversals and Corrections, for additional information. CLP-06 1032 Claim Filing Indicator Code Identifier (ID) Required 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 48/125 Code identifying type of claim Usage notes For many providers to electronically post the 835 remittance data to their patient accounting systems without human intervention, a unique, provider-specific insurance plan code is needed. This code allows the provider to separately identify and manage the different product lines or contractual arrangements between the payer and the provider. Because most payers maintain the same Originating Company Identifier in the TRN03 or BPR10 for all product lines or contractual relationships, the CLP06 is used by the provider as a table pointer in combination with the TRN03 or BPR10 to identify the unique, provider-specific insurance plan code needed to post the payment without human intervention. The value should mirror the value received in the original claim (2- 005 SBR09 of the 837), if applicable, or provide the value as assigned or edited by the payer. For example the BL from the SBR09 in the 837 would be returned as 12, 13, 15, in the 835 when more details are known. The 837 SBR09 code CI (Commercial Insurance) is generic, if through adjudication the specific type of plan is obtained a more specific code must be returned in the 835. The 837 and 835 transaction code lists for this element are not identical by design. There are some business differences between the two transactions. When a code from the 837 is not available in the 835 another valid code from the 835 must be assigned by the payer. Medicare will send “MB” for Part B and DME. Medicare will send “MA” for Part A. 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) MA Medicare Part A MB Medicare Part B MC Medicaid CLP-07 127 Payer Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier CLP07 is the payer's internal control number. Usage notes Use this number for the payer's internal control number. This number must apply to the entire claim. CLP-08 1331 Facility Type Code Min 1 Max 2 String (AN) Optional Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. Usage notes Since professional or dental claims can have different place of service codes for services within a single claim, default to the place of service of the first service line when the service lines are not all for the same place of service. This number was received in CLM05-1 of the 837 claim. CLP-09 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 49/125 Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type Usage notes This number was received in CLM05-3 of the 837 Claim. CLP-11 1354 Diagnosis Related Group (DRG) Code Min 1 Max 4 Identifier (ID) Optional Code indicating a patient's diagnosis group based on a patient's illness, diseases, and medical problems CLP-12 380 Diagnosis Related Group (DRG) Weight Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CLP12 is the diagnosis-related group (DRG) weight. Usage notes This is the adjudicated DRG Weight. CLP-13 954 Discharge Fraction Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%) CLP13 is the discharge fraction. Usage notes This is the adjudicated discharge fraction. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 50/125 CAS 0200 Detail > Header Number Loop > Claim Payment Information Loop > CAS Claim Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Payers must use this CAS segment to report claim level adjustments that cause the amount paid to differ from the amount originally charged. See 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. See the SVC TR3 Note #1 for details about per diem adjustments. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment must be the first non-zero adjustment and is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Required when dollar amounts and/or quantities are being adjusted at the claim level. If not required by this implementation guide, do not send. Example CASOAXX00000000000X000000000000000XXXX00 0000000000000XXXXX00000000000000XXXX0000000 00000000000XX0000000000000000000~ If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS- 07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 51/125 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR,	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
for a particular service within the claim being paid Usage notes Payers must use this CAS segment to report claim level adjustments that cause the amount paid to differ from the amount originally charged. See 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. See the SVC TR3 Note #1 for details about per diem adjustments. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment must be the first non-zero adjustment and is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Required when dollar amounts and/or quantities are being adjusted at the claim level. If not required by this implementation guide, do not send. Example CASOAXX00000000000X000000000000000XXXX00 0000000000000XXXXX00000000000000XXXX0000000 00000000000XX0000000000000000000~ If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS- 07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 51/125 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer/payee contractual agreement or a regulatory requirement resulted in an adjustment. OA Other adjustments 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. PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the claim level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in CLP04. Decimal elements 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). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes See section 1.10.2.4.1 for additional information. A positive value decreases the covered days, and a negative number increases the covered days. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 52/125 CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 53/125 Monetary amount CAS12 is the amount of the adjustment. Usage notes See CAS03. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. Usage notes See CAS04. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. Usage notes See CAS03. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. Usage notes See CAS04. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. Usage notes See CAS03. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 54/125 CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. Usage notes See CAS04. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 55/125 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Corrected Patient/Insured Name To supply the full name of an individual or organizational entity Usage notes Since the patient is always the insured for Medicare and Medicaid, this segment always provides corrected patient information for Medicare and Medicaid. For other carriers, this will always be the corrected insured information. Required when needed to provide corrected information about the patient or insured. If not required by this implementation guide, do not send. Example NM1741XXXXXXXXXXXXX*XXXCXX~ Variants (all may be used) NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Corrected Insured Identification Indicator (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 74 Corrected Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Corrected Patient or Insured Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Corrected Patient or Insured First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Corrected Patient or Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 56/125 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Corrected Patient or Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) C Insured's Changed Unique Identification Number NM1-09 67 Corrected Insured Identification Indicator Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 57/125 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Corrected Priority Payer Name To supply the full name of an individual or organizational entity Usage notes Provide any reference numbers in NM109. Use of this segment identifies the priority payer. Do not use this segment when the Crossover Carrier NM1 segment is used. Required when current payer believes that another payer has priority for making a payment and the claim is not being automatically transferred to that payer. If not required by this implementation guide, do not send. Example NM1PR2XX****XVXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Crossover Carrier Name NM1 Insured or Subscriber NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Corrected Priority Payer Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) AD Blue Cross Blue Shield Association Plan Code FI Federal Taxpayer's Identification Number NI National Association of Insurance Commissioners (NAIC) Identification This is the preferred ID unless XV is used. PI Payor Identification PP Pharmacy Processor Number XV Centers for Medicare and Medicaid Services PlanID 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 58/125 Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used. NM1-09 67 Corrected Priority Payer Identification Number Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 59/125 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Crossover Carrier Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the crossover carrier. Provide any reference numbers in NM109. The crossover carrier is defined as any payer to which the claim is transferred for further payment after being finalized by the current payer. Required when the claim is transferred to another carrier or coverage (CLP02 equals 19, 20, 21 or 23). If not required by this implementation guide, do not send. Example NM1TT2X***PIXXXXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Insured or Subscriber NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual TT Transfer To NM1-02 1065 Entity Type Qualifier Identifier (ID)	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 57/125 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Corrected Priority Payer Name To supply the full name of an individual or organizational entity Usage notes Provide any reference numbers in NM109. Use of this segment identifies the priority payer. Do not use this segment when the Crossover Carrier NM1 segment is used. Required when current payer believes that another payer has priority for making a payment and the claim is not being automatically transferred to that payer. If not required by this implementation guide, do not send. Example NM1PR2XX***XVXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Crossover Carrier Name NM1 Insured or Subscriber NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Corrected Priority Payer Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) AD Blue Cross Blue Shield Association Plan Code FI Federal Taxpayer's Identification Number NI National Association of Insurance Commissioners (NAIC) Identification This is the preferred ID unless XV is used. PI Payor Identification PP Pharmacy Processor Number XV Centers for Medicare and Medicaid Services PlanID 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 58/125 Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used. NM1-09 67 Corrected Priority Payer Identification Number Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 59/125 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Crossover Carrier Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the crossover carrier. Provide any reference numbers in NM109. The crossover carrier is defined as any payer to which the claim is transferred for further payment after being finalized by the current payer. Required when the claim is transferred to another carrier or coverage (CLP02 equals 19, 20, 21 or 23). If not required by this implementation guide, do not send. Example NM1TT2X***PIXXXXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Insured or Subscriber NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual TT Transfer To NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Crossover Carrier Name Min 1 Max 60 String (AN) Required Individual last name or organizational name Usage notes Name of the crossover carrier associated with this claim. NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 60/125 PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Otherwise, one of the other listed codes may be used. NM1-09 67 Crossover Carrier Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 61/125 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Insured or Subscriber To supply the full name of an individual or organizational entity Example NM1ILXXXXXXXXX***XXXXXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Other Subscriber Name NM1 Patient Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Corrected Priority Payer Identification Number (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Min 1 Max 1 Identifier (ID) Optional Code qualifying the type of entity NM102 qualifies NM103. NM1-03 1035 Corrected Priority Payer Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Name First Min 1 Max 35 String (AN) Optional Individual first name NM1-08 66 Identification Code Qualifier Min 1 Max 2 Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) NM1-09 67 Corrected Priority Payer Identification Number Min 2 Max 80 String (AN) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 62/125 Code identifying a party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 63/125 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes 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. 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. Example NM1GB2XXXXXXXXXXXXXMIXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber NM1 Patient Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Other Subscriber Identifier (NM1-09) is present, then the other is required Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual GB Other Insured NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Subscriber Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name Usage notes At least one of NM103 or NM109 must be present. NM1-04 1036 Other Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 64/125 Individual middle name or initial Usage notes When only one character is present this is assumed to be the middle initial. NM1-07 1039 Other Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) FI Federal Taxpayer's Identification Number Not Used when NM102=1. II Standard Unique Health Identifier for each Individual in the United States Use this code if mandated in a final Federal Rule. MI Member Identification Number Use this code when supplying the number used for identification of the subscriber in NM109. NM1-09 67 Other Subscriber Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes At least one of NM103 or NM109 must be present. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 65/125 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Patient Name To supply the full name of an individual or organizational entity Usage notes Provide the patient's identification number in NM109. This segment must provide the information from 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. Example NM1QC1XXXXXXXXXXXXXX*XXMIXXXXXXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber NM1 Other Subscriber Name NM1 Service Provider Name If either Identification Code Qualifier (NM1-08) or Patient Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual QC Patient NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Patient Last Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Patient First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Patient Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 66/125 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Patient Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes An example of this is when a Junior and Senior are covered under the same subscriber. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) MI Member Identification Number NM1-09 67 Patient Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code NM1-10 706 Entity Relationship Code Min 2 Max 2 Identifier (ID) Optional Code describing entity relationship NM110 and NM111 further define the type of entity in NM101. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 67/125 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Service Provider Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the rendering provider. An identification number is provided in NM109. This information is provided to facilitate identification of the claim within a payee's system. Other providers (e.g., Referring provider, supervising provider) related to the claim but not directly related to the payment are not supported and are not necessary for claim identification. Required when the rendering provider is different from the payee. If not required by this implementation guide, do not send. Example NM1822XXXXXXXXXXXXXXXXXXXX*XXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber NM1 Other Subscriber Name NM1 Patient Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 68/125 Individual middle name or initial Usage notes If this data element is used and contains only one character, it represents the middle initial. NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Patient First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Patient Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 66/125 Usage notes If this data element is used and contains only one character, it is assumed to represent the middle initial. NM1-07 1039 Patient Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes An example of this is when a Junior and Senior are covered under the same subscriber. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system/method of code structure used for Identification Code (67) MI Member Identification Number NM1-09 67 Patient Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code NM1-10 706 Entity Relationship Code Min 2 Max 2 Identifier (ID) Optional Code describing entity relationship NM110 and NM111 further define the type of entity in NM101. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 67/125 NM1 0300 Detail > Header Number Loop > Claim Payment Information Loop > NM1 Service Provider Name To supply the full name of an individual or organizational entity Usage notes This segment provides information about the rendering provider. An identification number is provided in NM109. This information is provided to facilitate identification of the claim within a payee's system. Other providers (e.g., Referring provider, supervising provider) related to the claim but not directly related to the payment are not supported and are not necessary for claim identification. Required when the rendering provider is different from the payee. If not required by this implementation guide, do not send. Example NM1822XXXXXXXXXXXXXXXXXXXXXXXX~ Variants (all may be used) NM1 Corrected Patient/Insured Name NM1 Corrected Priority Payer Name NM1 Crossover Carrier Name NM1 Insured or Subscriber NM1 Other Subscriber Name NM1 Patient Name Max use 1 Optional NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name Min 1 Max 60 String (AN) Optional Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 68/125 Individual middle name or initial Usage notes If this data element is used and contains only one character, it represents the middle initial. NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system/method of code structure used for Identification Code (67) BD Blue Cross Provider Number BS Blue Shield Provider Number FI Federal Taxpayer's Identification Number This is the preferred ID until the National Provider ID is mandated and applicable. For individual providers as payees, use this qualifier to represent the Social Security Number. MC Medicaid Provider Number PC Provider Commercial Number SL State License Number UP Unique Physician Identification Number (UPIN) XX Centers for Medicare and Medicaid Services National Provider Identifier Required value if the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate. Otherwise, one of the other listed codes may be used. NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 69/125 MIA 0330 Detail > Header Number Loop > Claim Payment Information Loop > MIA Inpatient Adjudication Information To provide claim-level data related to the adjudication of Medicare inpatient claims Usage notes When used outside of the Medicare and Medicaid community only MIA01, 05, 20, 21, 22 and 23 may be used. Either MIA or MOA may appear, but not both. This segment must not be used for covered days or lifetime reserve days. For covered or lifetime reserve days, use the Supplemental Claim Information Quantities Segment in the Claim Payment Loop. All situational quantities and/or monetary amounts in this segment are required when the value of the item is different than zero. Required for all inpatient claims when there is a need to report Remittance Advice Remark Codes at the claim level or, the claim is paid by Medicare or Medicaid under the Prospective Payment System (PPS). If not required by this implementation guide, do not send. Example MIA0000000000000000000000000000XXXXXX00000 000000000000000000000000000000000000000 0000000000000000000000000000000000000000000 0XXXXXXXXXXX0000000000~ Max use 1 Optional MIA-01 380 Covered Days or Visits Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity MIA01 is the covered days. Usage notes Implementers utilizing the MIA segment always transmit the number zero. See the QTY segment at the claim level for covered days or visits count. MIA-02 782 PPS Operating Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA02 is the Prospective Payment System (PPS) Operating Outlier amount. Usage notes See TR3 note 4. Decimal elements 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). This applies to all subsequent 782 elements. MIA-03 380 Lifetime Psychiatric Days Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA03 is the lifetime psychiatric days. MIA-04 782 Claim DRG Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 70/125 Monetary amount MIA04 is the Diagnosis Related Group (DRG) amount. MIA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA05 is the Claim Payment Remark Code. See Code Source 411. MIA-06 782 Claim Disproportionate Share Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA06 is the disproportionate share amount. MIA-07 782 Claim MSP Pass-through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA07 is the Medicare Secondary Payer (MSP) pass-through amount. MIA-08 782 Claim PPS Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA08 is the total Prospective Payment System (PPS) capital amount. MIA-09 782 PPS-Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 71/125 Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA19 is the professional component amount billed but not payable. MIA-20 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 72/125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA20 is the Claim Payment Remark Code. See Code Source 411. MIA-21 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA21 is the Claim Payment Remark Code. See Code Source 411. MIA-22 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 73/125 MOA 0350 Detail > Header Number Loop > Claim Payment Information Loop > MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required for outpatient/professional claims where there is a need to report a Remittance Advice Remark Code at the claim level or when the payer is Medicare or Medicaid and MOA01, 02, 08 or 09 are non-zero. If not required by this implementation guide, do not send. Either MIA or MOA may appear, but not both. All situational quantities and/or monetary amounts in this segment are;required when the value of the item is different than zero. Example MOA00000000000000XXXXXXXXXXXXXXXXXXXXX000 000000000000000000000~ Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%) MOA01 is the reimbursement rate. MOA-02 782 Claim HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes Decimal elements 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). This applies to all subsequent 782 elements. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 74/125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 73/125 MOA 0350 Detail > Header Number Loop > Claim Payment Information Loop > MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required for outpatient/professional claims where there is a need to report a Remittance Advice Remark Code at the claim level or when the payer is Medicare or Medicaid and MOA01, 02, 08 or 09 are non-zero. If not required by this implementation guide, do not send. Either MIA or MOA may appear, but not both. All situational quantities and/or monetary amounts in this segment are;required when the value of the item is different than zero. Example MOA00000000000000XXXXXXXXXXXXXXXXXXXXX000 000000000000000000000~ Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%) MOA01 is the reimbursement rate. MOA-02 782 Claim HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. Usage notes Decimal elements 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). This applies to all subsequent 782 elements. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 74/125 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 Claim ESRD Payment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Nonpayable Professional Component Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 75/125 REF 0400 Detail > Header Number Loop > Claim Payment Information Loop > REF Other Claim Related Identification To specify identifying information Usage notes Required when additional reference numbers specific to the claim in the CLP segment are provided to identify information used in the process of adjudicating this claim. If not required by this implementation guide, do not send. Example REFCEXXX~ Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 1L Group or Policy Number 6P Group Number 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. 28 Employee Identification Number CE Class of Contract Code EA Medical Record Identification Number F8 Original Reference Number 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. TJ Federal Taxpayer's Identification Number REF-02 127 Other Claim Related Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 76/125 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Claim Received Date To specify pertinent dates and times Usage notes Required whenever state or federal regulations or the provider contract mandate interest payment or prompt payment discounts based upon the receipt date of the claim by the payer. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. Example DTM05020250130~ Variants (all may be used) DTM Coverage Expiration Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the date that the claim was received by the payer. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 77/125 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Coverage Expiration Date To specify pertinent dates and times Usage notes Required when payment is denied because of the expiration of coverage. If not required by this implementation guide, do not send. Example DTM03620250130~ Variants (all may be used) DTM Claim Received Date DTM Statement From or To Date Max use 1 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 036 Expiration DTM-02 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year Usage notes This is the expiration date of the patient's coverage. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 78/125 DTM 0500 Detail > Header Number Loop > Claim Payment Information Loop > DTM Statement From or To Date To specify pertinent dates and times Usage notes Dates at the claim level apply to the entire claim, including all service lines. Dates at the service line level apply only to the service line where they appear. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. For retail pharmacy claims, the Claim Statement Period Start Date is equivalent to the prescription filled date. Required when the "Statement From or To Dates" are not supplied at the service (2110 loop) level. If not required by this implementation guide, may be provided at senders discretion, but cannot be required by the receiver. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM23220250130~ Variants (all may be used) DTM Claim Received Date DTM Coverage Expiration Date Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 232 Claim Statement Period Start If the claim statement period start date is conveyed without a subsequent claim statement period end date, the end date is assumed to be the same as the start date. This date or code 233 is required when service level dates are not provided in the remittance advice. 233 Claim Statement Period End If a claim statement period end date is conveyed without a claim statement period start date, then the start date is assumed to be different from the end date but not conveyed at the payer's discretion. See the note on code 232. DTM-02 373 Claim Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 79/125 PER 0600 Detail > Header Number Loop > Claim Payment Information Loop > PER Claim Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when there is a claim specific communications contact. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800)555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number. Example PERCXXXXEMXXXXXXEXXXXXXEXXXX~ If either Communication Number Qualifier (PER-05) or Claim Contact Communications Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number Extension (PER-08) is present, then the other is required Max use 2 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Claim Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 80/125 EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Communication Number Extension Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 81/125 AMT 0620 Detail > Header Number Loop > Claim Payment Information Loop > AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send/receive one AMT for each applicable non-zero value. Do not report any zero values. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTZL*00000~ Max use 13 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount AU	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
- Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 79/125 PER 0600 Detail > Header Number Loop > Claim Payment Information Loop > PER Claim Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when there is a claim specific communications contact. If not required by this implementation guide, do not send. When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (800)555-1212 would be represented as 8005551212). The extension number, when applicable, is identified in the next element pair (Communications Number Qualifier and Communication Number) immediately after the telephone number. Example PERCXXXXEMXXXXXXEXXXXXXEXXXX~ If either Communication Number Qualifier (PER-05) or Claim Contact Communications Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number Extension (PER-08) is present, then the other is required Max use 2 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named CX Payers Claim Office PER-02 93 Claim Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Required Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 80/125 EX Telephone Extension When used, the value following this code is the extension for the preceding communications contact number. FX Facsimile TE Telephone PER-06 364 Claim Contact Communications Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EX Telephone Extension PER-08 364 Communication Number Extension Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 81/125 AMT 0620 Detail > Header Number Loop > Claim Payment Information Loop > AMT Claim Supplemental Information To indicate the total monetary amount Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send/receive one AMT for each applicable non-zero value. Do not report any zero values. Required when the value of any specific amount identified by the AMT01 qualifier is non-zero. If not required by this implementation guide, do not send. Example AMTZL00000~ Max use 13 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount AU Coverage Amount Use this monetary amount to report the total covered charges. This is the sum of the original submitted provider charges that are considered for payment under the benefit provisions of the health plan. This excludes charges considered not covered (i.e. per day television or telephone charges) but includes reductions to payments of covered services (i.e. reductions for amounts over fee schedule and patient deductibles). DY Per Day Limit F5 Patient Amount Paid Use this monetary amount for the amount the patient has already paid. I Interest See section 1.10.2.9 for additional information. NL Negative Ledger Balance Used only by Medicare Part A and Medicare Part B. 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 AMT-02 782 Claim Supplemental Information Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes Decimal elements 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). This applies to all subsequent 782 elements. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 82/125 QTY 0640 Detail > Header Number Loop > Claim Payment Information Loop > QTY Claim Supplemental Information Quantity To specify quantity information Usage notes Use this segment to convey information only. It is not part of the financial balancing of the 835. Send one QTY for each non-zero value. Do not report any zero values. Required when the value of a specific quantity identified by the QTY01 qualifier is non- zero. If not required by this implementation guide, do not send. Example QTYLA0000~ Max use 14 Optional QTY-01 673 Quantity Qualifier Identifier (ID) Required Code specifying the type of quantity CA Covered - Actual CD Co-insured - Actual LA Life-time Reserve - Actual OU Outlier Days 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 QTY-02 380 Claim Supplemental Information Quantity Min 1 Max 15 Decimal number (R) Required Numeric value of quantity 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 83/125 2110 Service Payment Information Loop Max 999 Optional SVC 0700 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > SVC Service Payment Information To supply payment and control information to a provider for a particular service Usage notes See section 1.10.2.1.1 (Service Line Balancing) for additional information. The exception to the situational rule occurs with institutional claims when the room per diem is the only service line adjustment. In this instance, a claim level CAS adjustment to the per diem is appropriate (i.e., CASCO7825~). See section 1.10.2.4.1 for additional information. See 1.10.2.6, Procedure Code Bundling and Unbundling, and section 1.10.2.1.1, Service Line Balancing, for important SVC segment usage information. Required for all service lines in a professional, dental or outpatient claim priced at the service line level or whenever payment for any service line of the claim is different than the original submitted charges due to service line specific adjustments (excluding cases where the only service specific adjustment is for room per diem). If not required by this implementation guide, do not send. Example SVCHP>XX>XX>XX>XX>XX0000000000000000XXXXX000 000000000000HC>XXXXXX>XX>XX>XX>XX>X0000000000~ Max use 1 Required SVC-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC01 is the medical procedure upon which adjudication is based. - For Medicare Part A claims, SVC01 would be the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) Code (see code source 130) and SVC04 would be the Revenue Code (see code source 132). Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC01-1 qualifies the values in SVC01-2, SVC01-3, SVC01-4, SVC01-5, SVC01-6 and SVC01-7. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 84/125 AD American Dental Association Codes 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. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes C003-02 234 Adjudicated Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes This is the adjudicated procedure code or revenue code as identified by the qualifier in SVC01-1. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. SVC-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC02 is the submitted service charge. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 85/125 Usage notes Use this monetary amount for the submitted service charge amount. Decimal elements 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). This applies to all subsequent 782 elements. SVC-03 782 Line Item Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC03 is the amount paid this service. Usage notes Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. See 1.10.2.1, Balancing, for additional information. SVC-04 234 National Uniform Billing Committee Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service SVC04 is the National Uniform Billing Committee Revenue Code. Usage notes If the original claim and adjudication only referenced an NUBC revenue code, that is supplied in SVC01 and this element is not used. SVC-05 380 Units of Service Paid Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC05 is the paid units of service. Usage notes If not present, the value is assumed to be one. SVC-06 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC06 is the original submitted medical procedure. Usage notes Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send. Max use 1 Optional C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 86/125 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. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf
in C003-02 and C003-08. SVC-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC02 is the submitted service charge. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 85/125 Usage notes Use this monetary amount for the submitted service charge amount. Decimal elements 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). This applies to all subsequent 782 elements. SVC-03 782 Line Item Provider Payment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVC03 is the amount paid this service. Usage notes Use this number for the service amount paid. The value in SVC03 must equal the value in SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. See 1.10.2.1, Balancing, for additional information. SVC-04 234 National Uniform Billing Committee Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service SVC04 is the National Uniform Billing Committee Revenue Code. Usage notes If the original claim and adjudication only referenced an NUBC revenue code, that is supplied in SVC01 and this element is not used. SVC-05 380 Units of Service Paid Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SVC05 is the paid units of service. Usage notes If not present, the value is assumed to be one. SVC-06 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVC06 is the original submitted medical procedure. Usage notes Required when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim. If not required by this implementation guide, do not send. Max use 1 Optional C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type/source of the descriptive number used in Product/Service ID (234) C003-01 qualifies C003-02 and C003-08. Usage notes The value in SVC06-1 qualifies the value in SVC06-2, SVC06-3, SVC06-4, SVC06-5, SVC06-6 and SVC06-7. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 86/125 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. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code Medicare uses this code to reflect the Skilled Nursing Facility Group as well as the Home Health Agency Outpatient Prospective Payment System. N4 National Drug Code in 5-4-2 Format NU National Uniform Billing Committee (NUBC) UB92 Codes C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVC-07 380 Original Units of Service Count Min 1 Max 15 Decimal number (R) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 87/125 Numeric value of quantity SVC07 is the original submitted units of service. 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 88/125 DTM 0800 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > DTM Service Date To specify pertinent dates and times Usage notes Dates at the service line level apply only to the service line where they appear. If used for inpatient claims and no service date was provided on the claim then report the through date from the claim level. When claim dates are not provided, service dates are required for every service line. When claim dates are provided, service dates are not required, but if used they override the claim dates for individual service lines. Required when claim level Statement From or Through Dates are not supplied or the service dates are not the same as reported at the claim level. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver. For retail pharmacy claims, the service date is equivalent to the prescription filled date. For predeterminations, where there is no service date, the value of DTM02 must be 19000101. Use only when the CLP02 value is 25 - Predetermination Pricing Only - No Payment. When payment is being made in advance of services, the use of future dates is allowed. Example DTM15120250130~ Max use 2 Optional DTM-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 150 Service Period Start This qualifier is required for reporting the beginning of multi-day services. If not required by this implementation guide, do not send. 151 Service Period End This qualifier is required for reporting the end of multi-day services. If not required by this implementation guide, do not send. 472 Service This qualifier is required to indicate a single day service. If not required by this implementation guide, do not send. DTM-02 373 Service Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 89/125 CAS 0900 Detail > Header Number Loop > Claim Payment Information Loop > Service Payment Information Loop > CAS Service Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes An example of this level of CAS is the reduction for the part of the service charge that exceeds the usual and customary charge for the service. See sections 1.10.2.1, Balancing, and 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. Required when dollar amounts are being adjusted specific to the service or when the paid amount for a service line (SVC03) is different than the original submitted charge amount for the service (SVC02). If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a specific Claim Adjustment Group Code (CAS01). The six iterations (trios) of the Adjustment Reason Code related to the Specific Adjustment Group Code must be exhausted before repeating a second iteration of the CAS segment using the same Adjustment Group Code. The first adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CASOAXXXXX0000000000000XX00000000000000000 00XXX0000000000000000000000000X000000000000 0000000000000000XX000000000000000000000000XX XX0*00000~ If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS- 07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS- 10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS- 13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS- 16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS- 19) is required Max use 99 Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 90/125 If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment Usage notes Evaluate the usage of group codes in CAS01 based on the following order for their applicability to a set of one or more adjustments: PR, CO, PI, OA. See 1.10.2.4, Claim Adjustment and Service Adjustment Segment Theory, for additional information. (Note: This does not mean that the adjustments must be reported in this order.) CO Contractual Obligations Use this code when a joint payer/payee agreement or a regulatory requirement has resulted in an adjustment. OA Other adjustments 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. PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes Required to report a non-zero adjustment applied at the service level for the claim adjustment group code reported in CAS01. CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. Usage notes Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03 and CLP04. Decimal elements 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). This applies to all subsequent 782 elements. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. Usage notes A positive number decreases paid units, and a negative value increases paid units. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional 1/29/25, 8:52 PM CGS Medicare 835 Health Care Claim Payment/Advice (X221A1) - Stedi EDI Guides https://www.stedi.com/app/guides/view/cgs-medicare/health-care-claim-paymentadvice-x221a1/01H25JG91Y6872AS5ZZTC7NMQ4 91/125 Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. Usage notes See CAS03. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. Usage notes See CAS04. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CAS02. CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. Usage notes See CAS03. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. Usage notes See CAS04. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code	CGS Medicare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf

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