RECORD ONE FIELD NO. FIELD NAME PIC L/R FROM TO · PDF filerecord one field no. field name. pic l/r: from to: loop id segment: element rqmt: comments 1: intermediary number x10: l

Attachment 1

CR 835 Flat File - 5010A1

Legend: Changed field highlighted in yellow

Usa

ge

405

R

R

R

R

R

R

R

R

R

R

R

R

R

R

R

R

R

R

R

R

Usa

ge R

R

R

R

R

R

R

R

N/U

R

R

R

R

R

S

S

S

S

S

S

S

Usa

ge S

S

S

S 35141BPR15 Receiver or Provider Acct # PIC X(35 AN 1--35

138 3DA,SG

12

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

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

124 201

Length Record Repeat Comment

BPR12 DFI ID # Qualifier PIC X(2) ID 2--2

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

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

835 TR3 5010A1

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

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

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

Not used by Part B115 9=TRN04

105 10

BPR11 Originating Co Supplemental Code PIC X(9) AN 9--9

BPR10 Payer Identifier PIC X(10) AN 10--10

70 35

67 3

BPR09 Sender Bank Acct # PIC X(35) AN 1--35

DABPR08 Acct # Qualifier PIC X(3) ID 1--3

55 12

53 2

BPR07 Sender DFI Identifier PIC X(12) AN 3--12

01BPR06 DFI ID # Qualifier PIC X(2) ID 2--2

43 10CCP,CTX

40 3

BPR05 Payment Format Code PIC X(10) ID 1--10

ACH,CHK,NONBPR04 Payment Method Code PIC X(3) ID 3--3

39 1C

21 18

BPR03 Credit or Debit Flag Code PIC X(1) ID 1--1

BPR02 Total Actual Provider Payment Amt

05 Total Actual Provider Payment

Amt

- Group PIC X(18)

05 Total Actual Provider Payment

Amt

- Group REDEF REDEFINES

Total Actual Provider Payment Amt R 1--18

19 2C, D, H, I ,P, U, X

1 18 1

BPR01 Transaction Handling Code PIC X(2) ID 1--2

69 BPRBPR Financial Information 1 ----------- 1

Added field ST03 RE: AtST03 Implementation Convention Reference AN 1-35

22 9=SE02

19 3

ST02 Transaction Set Control Number PIC X(9) AN 4--9

835ST01 Transaction Set Identifier Code PIC X(3) ID 3--3

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

78 12005010X221A1

76 2

GS08 Version/Release/Industry ID code PIC X(12) AN 1--12

XGS07 Responsible Agency Code PIC X(2) ID 1--2

67 9Increament by one; beginning at 001

59 8

GS06 Group Control NumberPIC 9(9)

N0 1--9

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

51 8See ISA09

Start Length Record Repeat Comment

GS04 Date PIC 9(8) DT 8--8

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

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

835 TR3 5010A1




36 15Application Receiver's Code

15

GS03 Application Receiver's Code PIC X(15) AN 2--15

21GS02 Application Sender's Code PIC X(15) AN 2--15 Application Sender's Code

19 2HP

18 1

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

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

1104ISA16 Component Element Separator PIC X(1) 1--1 Translator Generated

103 1P,T

1

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

102ISA14 Acknowledgement Requested PIC X(1) ID 1--1 0

93 9

YJJJ00000 where Y is the last digit of the cycle year,

JJJ is the Julian date of the cycle and 00000 is a

sequential number that starts with 00001 and

increments by 1.

5

ISA13 Interchange Control Number

PIC 9(9)

N0 9--9

88ISA12 Interchange Control Version Number PIC X(5) ID 5--5 00501

87 1(Translator Generated)

4

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

83

Format is YYMMDD with CC (20) appended

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

77 6Interchange Date (Translator Generated)

15

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

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

60 201,14,20,27,28,

29,30,33,ZZ

15

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

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

43 201,14,20,27,28,

29,30,33,ZZ

10

ISA05

Interchange ID Qualifier

PIC X(2) ID 2--2

33ISA04 Security Information PIC X(10) AN 10--10 Blank

31 200

10

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

21ISA02 Authorization Information PIC X(10) AN 10--10 Blank

19 200

18 1

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

ISA 1ISA Interchange Control Header 1 --------

4 46 4

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

835 TR3 5010A1

Element COBOL PIC ID Min/Max Loop Loop Repeat Values


1

Attachment 1



835 TR3 5010A1

R

N/U

R

R

R

R

S

S

S

R

R

N/U

S

R

R

N/U

Usa

ge

Req

S

R

R

N/U

R

R

R

S

S

N/U

R

R

S

R

R

R

R

S

N/U

Usa

ge

Req

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

Length

Record Repeat

Comment

-N406

Page #

Loop ID

Loop Seq Seg ID Seg. Seq. Start

Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values


835 TR3 5010A1




N405- Location Qualifier ID 1-2

66 3

15

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

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

49 2

30

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

19N401 Payer City Name PIC X(30) AN 2--30

N4 1 18 190 1000AN4 Payer City, State, Zip 1 1000A

74 55

55

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

19N301 Payer Address Line PIC X(55) AN 1--55

N3 1 18 189 1000AN3 Payer Address 1 1000A

-NM106

N105- Entity Relationship Code ID 2--2

84 80

2

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

82

All names expanded to 60 per HIGLAS

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

22 60

3

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

19N101 Entity Identifier Code PIC X(3) ID 2--3 PR

N1 1 18 11 87 1000AN1 Payer Identification 1 1000A

-DTM06

DTM03- Time TM 4-8

22 8CCYYMMDD

3

DTM02 Production Date05 Production Date - Group PIC

X(8)DT 8--8

19DTM01 Date Time Qualifier PIC X(3) ID 3--3 405

DTM 1 18 11 85DTM Production Date 1 -----------

Length

Record Repeat

Comment

-REF04

Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values


835 TR3 5010A1




REF03- Description AN 1-80

22 50

3

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

84 19REF01 Receiver ID Qualifier PIC X(3) ID 2--3 F2

REF 1 18 11REF Version Identification 1 -----------

-REF04

REF03- Description AN 1-80

22 50

3

REF02 Receiver Identifier PIC X(50) AN 1--50

82 19REF01 Receiver ID Qualifier PIC X(3) ID 2--3 EV

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

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

Change max from 30 to 50 RE: Attahment w/81 50=BPR011

10

TRN04 Originating Co Supplemental Code PIC X(50) AN 1--50

71TRN03 Payer Identifier PIC X(10) AN 10--10

21 50

2

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

19TRN01 Trace Type Code PIC X(2) ID 1--2 1

TRN 1 18 11 77TRN Reassociation Trace Number 1 -----------

-BPR21

BPR17- Business Function Code ID 1-3

176 8BPR16

Check Issue or EFT Effective Date

05 Check Issue or EFT Effective

Date - Group PIC X(8)

05 Check Issue or EFT Effective

Date - Group REDEF

REDEFINESDT 8--8

2

Attachment 1



835 TR3 5010A1

S

R

R

N/U

S

R

S

S

S

S

S

S

S

N/U

R

R

S

S

S

S

S

S

S

Usa

ge

Req

N/U

S

R

N/U

R

R

N/U

R

R

R

R

R

N/U

S

R

S

S

R

S

S

S

N/U

835 TR3 5010A1




66 3

N405- Location Qualifier ID 2--2

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

51 15

49 2

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

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

19 30

1 18 1

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

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

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

19 55

1 18 1

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

104 1000B N3N3 Payee Address 1 1000B

-N106

84 80

N105- Entity Relationship Code ID 2--2

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

82 2XX, FI, XV

22 60 All names expanded to 60 per HIGLAS

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

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

19 3PE

1 18 1

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

102 1000B N1N1 Payee Identification 1 1000B 1

- PER09

PER05- Cummunication Number Qualifier ID 2--2

83 256

81 2

PER04 Payer Contact Communication

#

PIC X(256) AN 1-256

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

21 60

19 2

PER02 Name PIC X(60) AN 1-60

ICPER01 Contact Function Code PIC X(2) ID 2--2

PER 1 18 11000A 100 1000APER Payer Web Site 1

Start Length

Record Repeat

Comment

PER09 Contact Inquiry Reference AN 1-20

Values Page #

Loop ID

Loop Seq Seg ID Seg. Seq.

Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat


835 TR3 5010A1




599 256

2


#

PIC X(256) AN 1-256

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

341 256

2


#

PIC X(256) AN 1-256

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

83 256

2


#

PIC X(256) AN 1-256

81


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

21 60

2

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

19PER01 Contact Function Code PIC X(2) ID 2--2 BL

PER 1 18 197 1000APER Payer Technical Contact Information 1 1000A

256


599PER08 Payer Contact Communication

#

PIC X(256) AN 1-256

597 2EX

256

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


#

PIC X(256) AN 1-256

339 2EM,EX,FX,TE

256

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


#

PIC X(256) AN 1-256

81 2EM,FX,TE

60 All names expanded to 60 per HIGLAS

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

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

19 2CX

18 1

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

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

-REF04

50

REF03- Description AN 1--80

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

19 32U

18 4

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

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

3

Attachment 1



835 TR3 5010A1

Usa

ge

Req

S

S

R

R

N/U

S

N/U

S

R

S

R

R

R

Usa

ge

Req

R

R

N/U

N/U

N/U

N/U

N/U

N/U

N/U

S

N/U

S

N/U

Usa

ge

Req

S

S

N/U

S

S

S




18 Only Part A220

Only Part A

TS322 Total Patient Reimbursement Amount 05 Total Patient Reimbursement

Amount - Group PIC R 1--18

202 18

18 Only Part A

TS321 Total MSP Patient Liability Met Amount05 Total MSP Patient Liability Met


184TS320 Total Professional Component Amount05 Total Professional Component

Amount - Group PIC X(18)R 1--18

18 Only Part A

TS319 Total Deductible Amount R 1--18

166

Only Part A

TS318 Total HCPCS Payable Amount05 Total HCPCS Payable Amount

- Group PIC X(18)R 1--18

148 18

Length

Record Repeat

Comment

TS317 Total HCPCS Reported Charge Amount05 Total HCPCS Reported

Charge Amount - Group R 1--18

Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values


835 TR3 5010A1




130 18 Only Part A

TS316 Total Coinsurance Amount

TS315 Total Non-Lab Charge Amount05 Total Non-Lab Charge Amount -

Group PIC X(18)R 1--18

112 18 Only Part A

TS314 Total Blood Deductible Amount R 1--18

TS313 Total MSP Payer Amount05 Total MSP Payer Amount -


TS312 Total Gramm-Rudman Reduction Amount

TS 311 Total Contractual Adjustment Amount

TS 310 Total Interest Amount

TS 309 Total Provider Amount

TS 308 Total Denied Charge Amount

TS307 Total Noncovered Charge Amount

94 18

TS306 Total Covered Charge Amount

TS305 Total Claim Change Amount05 Total Claim Change Amount -


79 15

Start Length

Record Repeat

Comment

TS304 Total Claim Count05 Total Claim Count - Group PIC

X(15)R 1--15

Values Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat


835 TR3 5010A1




71 8CCYYMMDD

2 Part B will use either 11 or 99

TS303 Fiscal Period Date05 Fiscal Period Date - Group PIC

x(8)DT 8--8

69

Legacy in case of VA pricing

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

19 50NPI

18 1

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

112 2000 TS3 1TS3 Provider Summary Information 1 2000 1

6FISS uses TTYYMM -

Facility Code/year/Month. MCS uses 1 for 19LX01 Assigned #

05 Assigned Number -GROUP

PIC X(6)N0 1--6 0,1, TTYYMM

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

-RDM05

RDM04 Reference Identifier

81 256

60

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

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

19 2BM, EM, FT, OL

18

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

109 1RDM Remittance Delivery Method 1 1000B

-REF04

50

REF03- Description AN 1 80

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

19 3TJ

18 >1

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

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

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

Length

Record Repeat

Comment

-N406

Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values


4

Attachment 1



835 TR3 5010A1

Usa

ge

Req

S

S

S

S

S

S

Usa

ge

Req

S

S

S

S

S

S

Usa

ge

Req

S

S

S

S

S

S

Usa

ge

Req

S

S

S

S

R

R

R

R


835 TR3 5010A1




59 18

57 2

CLP03 Total Claim Charge Amount05 Total Claim Charge Amount -

Group PIC R 1--18

1,2,3,4, 19, 20, 21, 22,

23CLP02 Claim Status Code PIC X(2) ID 1--2

19 38

1 18 1

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

123 2100 CLPCLP Claim Level Data 1 2100 >1

322 18TS219 Total PPS DSH DRG Amount05 Total PPS DSH DRG Amount -

Group PIC R 1--18

304 18

286 18

TS218 Total PSP Capital HSP DRG Amount05 Total PSP Capital HSP DRG


TS217 Total PPS Capital FSP DRG Amount05 Total PPS Capital FSP DRG


271 15

Start Length

Record Repeat

Comment

TS216 Average DRG Weight05 Average DRG Weight - Group

PIC X(15)R 1--15

Values Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat


835 TR3 5010A1




253 18

15

TS215 Total MSP Pass-Through Amount05 Total MSP Pass-Through


238TS214 Total Noncovered Day Count05 Total Noncovered Day Count-

Group PIC R 1--15

223 15

15

TS213 Total Covered Day Count05 Total Covered Day Count -


208TS212 Total Cost Report Day Count05 Total Cost Report Day Count -

Group PIC R 1--15

193 15

15

TS 211 Total Discharge Count05 Total Discharge Count - Group

PIC X(15)R 1--15

178

Comment

TS 210 Average DRG Length of Stay05 Average DRG Length of Stay -

Group PIC R 1--15

Seg ID Seg. Seq. Start Length

Record RepeatLoop Repeat

Values Page #

Loop ID

Loop Seq

Element

Identifier

COBOL PIC

ID Min/Max Loop


835 TR3 5010A1




160 18TS 209 Total Cost Outlier Amount05 Total Cost Outlier Amount -


142 18

127 15

TS 208 Total Day Outlier Amount05 Total Day Outlier Amount -


TS207 Total Outlier Day Count05 Total Outlier Day Count -


109 18

91 18

TS206 Total Indirect Medical Education Amount05 Total Indirect Medical

Education Amount - Group R 1--18

TS205 Total Capital Amount05 Total Capital Amount - Group

PIC X(18)R 1--18

73 18

Start Length

Record Repeat

Comment

TS204 Total Disproportionate Amount05 Total Disproportionate Amount -


Values Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat


835 TR3 5010A1




55 18

18

TS203 Total Hospital Specifc Amount05 Total Hospital Specifc Amount -


37TS202 Total Federal Specific Amount05 Total Federal Specific Amount -


19 18

18 1 N/U for Part B

TS201 Total DRG Amount05 Total DRG Amount - Group

PIC X(18)R 1--18

117 2000 TS2 1TS2 Provider Supplemental Summary Info 1 2000

18 Only Part A253

Only Part A

TS324 Total PIP Adjustment Amount05 Total PIP Adjustment Amount -

Group PIC R 1--18

238 15

Length

Record Repeat

Comment

TS323 Total PIP Claim Count05 Total PIP Claim Count - Group

PIC X(15)R 1--15

Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values


835 TR3 5010A1

5

Attachment 1



835 TR3 5010A1

Usa

ge

Req

R

S

R

S

S

S

N/U

S

S

S

N/U

S

R

R

Usa

ge

Req

R

S

S

S

S

S

S

S

Usa

ge

Req

S

S

S

S

S

S

S

S

Usa

ge

Req

S

R

R

R

S 23 60 All names expanded to 60 per HIGLASNM103 Patient Last Name PIC X(60) AN 1--60

22 11

19 3

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

QCNM101 Entity Identifier Code PIC X(3) ID 2--3

NM1 1 18 12100 137 2100NM1 Patient Name 1

234 15

Start Length

Record Repeat

Comment

CAS19 Adjustment Quantity05 Adjustment Quantity - Group

PIC X(15)R 1--15

Values Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat


835 TR3 5010A1




216 18

5

CAS18 Adjustment Amount05 Adjustment Amount - Group

PIC X(18)R 1--18

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

196 15

18


PIC X(15)R 1--15

178CAS15 Adjustment Amount05 Adjustment Amount - Group

PIC X(18)R 1--18

173 5

15

CAS14 Adjustment Reason Code PIC X(5) ID 1--5

158CAS13 Adjustment Quantity05 Adjustment Quantity - Group

PIC X(15)R 1--15

140 18

5


PIC X(18)R 1--18

135

Comment




Values Page #

Loop ID

Loop Seq

Element

Identifier

COBOL PIC

ID Min/Max Loop


835 TR3 5010A1




120 15CAS10 Adjustment Quantity05 Adjustment Quantity - Group

PIC X(15)R 1--15

102 18

97 5


PIC X(18)R 1--18


82 15

64 18


PIC X(15)R 1--15


PIC X(18)R 1--18

59 5

44 15



PIC X(15)R 1--15

26 18

Start Length

Record Repeat

Comment


PIC X(18)R 1--18

Values Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat


835 TR3 5010A1




21 5

2 Group code CR has been deleted


19CAS01 Claim Adjustment Group Code PIC X(2) ID 1--2 CO, OA, PR

CAS 1 18 99129 2100CAS Claim Adjustment 99 2100

10

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

187

Part A only

CLP13 Discharge Fraction05 Discharge Fraction - Group

PIC X(10)R 1--10

172 15

4 Part A only

CLP12 DRG Weight05 DRG Weight - Group PIC

X(15)R 1--15

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

1 Required when the information was

CLP10 Patient Status Code ID 1-2

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

165 2

50

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

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

113 2MA/MB

18

CLP06 Claim Filling Indicator Code PIC X(2) ID 1--2

95CLP05 Patient Responsibility Amount05 Patient Responsibility Amount -


77 18

Length

Record Repeat

Comment

CLP04 Claim Payment Amount05 Claim Payment Amount -


Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values

6

Attachment 1



835 TR3 5010A1

S

S

N/U

S

S

S

N/U

S

S

R

R

S

S

S

N/U

S

Usa

ge

Req

S

S

N/U

S

R

R

S

S

S

N/U

S

R

R

N/U

S

R

R

R

N/U

N/U

N/U

N/U

R

R

N/U

Usa

ge

Req Start Length

Record Repeat

Comment

-NM112

Values Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat


835 TR3 5010A1




80

NM110- Entity Relathionship Code ID 2--2

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

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

NM107 Name suffix AN 1-10

NM106 Name Prefix AN 1-10

NM105 Middle name AN 1-25

60 All names expanded to 60 per HIGLAS

NM104 First name AN 1-35

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

22 12

3


19NM101 Entity Identifier Code PIC X(3) ID 2--3 TT

NM1 1 18 1150 2100NM1 Crossover Carrier Name 1 2100

-NM112

NM110- Entity Relationship Code ID 2--2

155 80NPI

2

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

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

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

Required when NM102=1, and NM103


118 25

35 All last names expanded to 35 per

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

83


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

23 60

1

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

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

19 382

18 1

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

146 2100 NM1 1NM1 Service Provider Name 1 2100

-NM112

80

Please see Attachment 3 w CR 9700 to

determine when to provide the MBI in this field.


155NM109

Corrected Ins Identification Indicator PIC X(80)

AN 2--80

153 2C

Length

Record Repeat

Comment

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

Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values


835 TR3 5010A1




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


118 25

83 35 All last names expanded to 35 per

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


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

23 60

22 1

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

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

19 374

1 18 1

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

143 2100 NM1NM1 Corrected Patient/Insured Name 1 2100

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

-NM112

155 80


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

153 2HN, MI

143 10

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

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

118 25


All last names expanded to 35 per

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

83 35NM104 Patient First Name PIC X(35) AN 1--35

7

Attachment 1



835 TR3 5010A1

S

R

R

R

N/U

N/U

N/U

N/U

R

R

N/U

S

R

S

Usa

ge

Req

S

S

S

S

S

S




171 18

18

MIA08 CLAIM PPS CAPITAL AMOUNT

05 CLAIM PPS CAPITAL

AMOUNT - Group

PIC X(18)


AMOUNT REDEF REDEFINES

CLAIM PPS CAPITAL AMOUNT -

Group


AMOUNT PIC

S9(8)V99

10 CLAIM PPS CAPITAL R 1--18

153MIA07 CLAIM MSP PASS THRU AMT05 CLAIM MSP PASS THRU

AMT - Group PIC R 1--18

135 18

50

MIA06 CLAIM DSH AMOUNT05 CLAIM DSH AMOUNT -


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

67 18

15

MIA04 CLAIM DRG AMOUNT

05 CLAIM DRG AMOUNT -

Group PIC X(18)

05 CLAIM DRG AMOUNT

REDEF REDEFINES

CLAIM DRG AMOUNT -Group

10 CLAIM DRG AMOUNT PIC

S9(8)V99

10 CLAIM DRG AMOUNT Filler

PIC X(8)

R 1--18

52

Comment

MIA03 Lifetime Psychiatric Days Count

05 Lifetime Psychiatric Days

Count - Group PIC

X(15)


Count REDEF REDEFINES

Lifetime Psychiatric Days Count -

Group


Count PIC

S9(3)


Count Filler PIC

X(12)

R 1--15



Values Page #

Loop ID

Loop Seq

Element

Identifier

COBOL PIC

ID Min/Max Loop


835 TR3 5010A1




34 18MIA02 PPS Operating Outlier Amount

05 PPS Operating Outlier Amount -

Group PIC X(18)

05 PPS Operating Outlier Amount

REDEF REDEFINES

PPS Operating Outlier Amount -

Group

10 PPS Operating Outlier Amount

PIC

S9(8)V99

10 PPS Operating Outlier

R 1--18

19 15

1 18 1 either MIA or MOA but not both

MIA01 Covered Days or Visits Count05 Covered Days or Visits Count -


159 2100 MIAMIA Inpatient Adjudication Information 1 2100

Not used by MedicareN/A 156NM1 Other Subscriber Name

-NM112

85 80

NM110- Entity Relationship Code ID 2-2

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

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

NM107 Name suffix AN 1-10


NM105 middle name AN 1-25

23 60 All names expanded to 60 per HIGLAS

NM104 First name AN 1-35

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

22 12

19 3


PRNM101 Entity Identifier Code PIC X(3) ID 2--3

NM1 1 18 12100 153 2100NM1 Corrected Priority Payer Name 1

8

Attachment 1



835 TR3 5010A1

Usa

ge

Req

S

S

S

S

S

Usa

ge

Req

S

S

S

S

S

Usa

ge

Req

S

S

S

S

S

S 584 18MIA24 PPS CAPITAL EXCEPTION AMT

05 PPS CAPITAL EXCEPTION

AMT

- Group PIC X(18)


AMT REDEF REDEFINES

PPS CAPITAL EXCEPTION

AMT -Group


AMT PIC S9(8)V99


AMT Filler PIC X(8)

R 1--18

534 50

484 50

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


434 50

384 50



366 18

Start Length

Record Repeat

Comment

MIA19 NON PAY PROF COMP AMT

05 NON PAY PROF COMP AMT -

Group PIC X(18)

05 NON PAY PROF COMP AMT

REDEF REDEFINES

NON PAY PROF COMP AMT -

Group


PIC S9(8)V99


Filler PIC X(8)

R 1--18

Values Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat


835 TR3 5010A1




348 18

18

MIA18 CLAIM INDIRECT TEACHING

05 CLAIM INDIRECT TEACHING

- Group PIC X(18)


REDEF REDEFINES

CLAIM INDIRECT TEACHING -

Group


PIC

S9(8)V99


Filler PIC

R 1--18

330MIA17 CLAIM PPS OUTLIER AMOUNT05 CLAIM PPS OUTLIER

AMOUNT - Group R 1--18

312 18

15

MIA16 PPS OPER FSP SPEC DRG AMT05 PPS OPER FSP SPEC DRG


297MIA15 COST REPORT DAY COUNT05 COST REPORT DAY COUNT


279 18

Length

Record Repeat

Comment

MIA14 PPS OPER HSP SPEC DRG AMT S9(8)V9905 PPS OPER HSP SPEC DRG


Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values


835 TR3 5010A1




261 18

243 18

MIA13 PPS CAPITAL IME AMOUNT05 PPS CAPITAL IME AMOUNT -

Group PIC R 1--18

MIA12 OLD CAPITAL AMOUNT05 OLD CAPITAL AMOUNT -


225 18

207 18

MIA11 PPS CAPITAL DSH DRG AMT05 PPS CAPITAL DSH DRG


MIA10 PPS CAPITAL HSP DRG AMT05 PPS CAPITAL HSP DRG

AMT - Group R 1--18

189 18

Start Length

Record Repeat

Comment

MIA09 PPS CAPITAL FSP DRG AMT05 PPS CAPITAL FSP DRG

AMT - Group R 1--18

Values Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat


835 TR3 5010A1

9

Attachment 1



835 TR3 5010A1

S

S

S

S

S

S

Usa

ge

Req

S

S

S

S

S

R

R

S

S

R

R

N/U

Usa

ge

Req

S

R

R

N/U

S

R 19 3050DTM01 Date/Time Qualifier PIC X(3) ID 3--3

DTM 1 18 12100 177 2100DTM Claim Received Date 1

-DTM06

DTM03- Time TM 4-8

22 8CCYYMMDD

19 3

DTM02 Coverage Expiration Date

05 Coverage Expiration Date -

Group PIC x(8)

05 Coverage Expiration Date - DT 8--8

036DTM01 Date/Time Qualifier PIC X(3) ID 3--3

DTM 1 18 12100 175 2100

Start Length

Record Repeat

Comment

DTM Coverage Expiration Date 1

Values Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat


835 TR3 5010A1




-DTM06

8

DTM03- Time TM 4-8

22DTM02 Claim Date05 Claim Date - Group PIC X(8)

05 Claim Date - Group REDEF DT 8--8 CCYYMMDD

19 3232, 233

18 2

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

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

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

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

19 3EA, 6P, 28, F8

18 N/U by Part B

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

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

18315MOA09 Nonpayable Professional Comp Amt

05 Nonpayable Professional

Comp Amt - Group PIC

X(18) R 1--18

297 18

50

MOA08 Claim ESRD Payment Amount05 Claim ESRD Payment Amount -

Group PIC R 1--18

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

197 50

Length

Record Repeat

Comment

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

Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values


835 TR3 5010A1




147 50

97 50



47 50

29 18

N/U for Part B


N/U for Part B

MOA02 Claim HCPCS Payable Amount

05 Claim HCPCS Payable

Amount - Group

PIC X(18)


Amount REDEF REDEFINES

Claim HCPCS Payable Amount -

Group


Amount PIC

S9(8)V99


Amount Filler PIC

X(8)

R 1--18

19 10

1 18 1 Inpatient Claims. Use either MIA or MOA but

MOA01 Reimbursement Rate

05 Reimbursement Rate - Group

PIC X(10)

05 Reimbursement Rate REDEF

REDEFINES

Reimbursement Rate -Group

10 Reimbursement Rate PIC

S9(4)V9999

10 Reimbursement Rate Filler PIC

X(2)

R 1--10

166 2100 MOAMOA Outpatient Adjudication Information 1 2100

10

Attachment 1



835 TR3 5010A1

R

N/U

S

R

S

R

R

S

S

S

S

N/U

Usa

ge

Req

S

R

R

N/U

S

R

R

N/U

S

R

R

R

S

S

S

Usa

ge

Req

S

N/U

N/U

R

R

S

S

S

R

R

S

S

S

S

S Mediare will populate if received on the claim234 80

2

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

232-06-6 Procedure Modifier PIC X(2) AN 2--2

230 2

2

-06-5 Procedure Modifier PIC X(2) AN 2--2


226 2

48


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

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

SVC06 Composite Medical Procedure Identifier

161 15

48

SVC05 Units of Service Paid Count05 Units of Service Paid Count -

Group PIC R 1--15

113SVC04 NUBC Revenue Code PIC X(48) AN 1--48

95 18

18

SVC03 Line Item Provider Payment05 Line Item Provider Payment -

Group PIC R 1--18

77SVC02 Line Item Charge Amount05 Line Item Charge Amount -


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

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

75 2

Length

Record Repeat

Comment


Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values


835 TR3 5010A1





71 2

2



21 48

2

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

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

18 1

SVC01 Composite Medical Procedure Identifier

186 2110 SVC 1SVC Service Payment Information 1 2110 999

-QTY04

N/U

15

QTY03- Composite Unit of Measure AN 1-30

21QTY02 Claim Supplemental Information Quantity05 Claim Supplemental

Information Quantity - Group R 1--15

19 2CA, CD, LA, OU ZK, ZL, ZM, ZN, ZO

18 14

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

184 2100 QTY 1QTY Claim Supplemental Infor Quantity 14 2100

AMT03 Credit/Debit Flag Code ID 1-1

22 18

3

AMT02 Claim Supplemental Information Amt

05 Claim Supplemental

Information Amt - Group

PIC X(18)

05 Claim Supplemental

Information Amt REDEF

REDEFINESR 1--18

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

AMT 1 18 13182 2100

Length

Record Repeat

Comment

AMT Claim Supplemental Information 13 2100

Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values


835 TR3 5010A1





599 256

597 2

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

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

341 256

339 2

PER06 Claim Contact Communication

#

PIC X(256) AN 1--256

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

83 256

81 2

PER04 Claim Contact Communication

#

PIC X(256) AN 1--256

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

21 60

19 2

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

CXPER01 Contact Function Code PIC X(2) ID 2--2

PER 1 18 22100 179 2100PER Claim Contact Information 2

-DTM06

DTM03- Time TM 4-8

22 8CCYYMMDDDTM02 Claim Received Date05 Claim Received Date - Group

PIC X(8)DT 8--8

11

Attachment 1



835 TR3 5010A1

N/U

Usa

ge

Req

S

S

R

R

N/U

S

R

R

R

S

Usa

ge

Req

S

S

S

S

S

S

S

S

S

Usa

ge

Req

S

S

S

S

S

S

R

R

N/U

S

R

R

N/UREF03- Description AN 1--80

22 50

19 3

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

6RREF01 Reference ID Qualifier PIC X(3) ID 2--3

REF 1 18 12110 206 2110REF Line Item Control Number 1

-REF04


22 50

19 3 LU - required if the specific site of service

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

LU, 1S, APC, RBREF01 Reference ID Qualifier PIC X(3) ID 2--3

REF 1 18 82110 204 2110REF Service Identification 8

234 15

216 18


PIC X(15)R 1--15


PIC X(18)R 1--18

211 5

196 15



PIC X(15)R 1--15

178 18

Start Length

Record Repeat

Comment


PIC X(18)R 1--18

Values Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat


835 TR3 5010A1




173 5

15



PIC X(15)R 1--15

140 18

5


PIC X(18)R 1--18

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

120 15

18


PIC X(15)R 1--15


PIC X(18)R 1--18

97 5

15



PIC X(15)R 1--15

64 18

Length

Record Repeat

Comment


PIC X(18)R 1--18

Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values


835 TR3 5010A1




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

44 15

18


PIC X(15)R 1--15


PIC X(18)R 1--18

21 5

2 Group Code CR has been deleted


19CAS01 Claim Adjustment Group Code PIC X(2) ID 1--2 CO,OA,PR

CAS 1 18 99196 2110CAS Service Adjustment 99 2110

-DTM06

DTM03- Time TM 4--8

22 8CCYYMMDD

3

DTM02 Service Date05 Service Date - Group PIC X(8)

05 Service Date - Group REDEF DT 8--8

19DTM01 Date Time Qualifier PIC X(3) ID 3--3 150, 151, 472

DTM 1 18 2194 2110DTM Service Date 2 2110

314 15

Length

Record Repeat

Comment

SVC07 Original Units of Service Count05 Original Units of Service Count


Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values


835 TR3 5010A1




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

12

Attachment 1



835 TR3 5010A1

Usa

ge

Req

S

R

R

N/U

S

R

R

N/U

S

R

R

N/U

S

S

R

R

Usa

ge

Req

S

R

R

R

R

S

R

S

R

S




149 50

147 2

Instruction to use TL - CR from OFM

-05-2 Provider Adjustment IdentifierPIC X(50)

AN 1--50

50, 51, 72, AP, B2, B3,

BD, BN, C5, CS, CV,

DM, E3, FB, GO, HM,-05-1 Adjustment Reason Code

PIC X(2)

ID 2--2

129 18

PLB05 Adjustment Identifier

PLB04 Provider Adjustment Amount

05 Provider Adjustment Amount -

Group PIC X(18)

05 Provider Adjustment Amount

REDEF REDEFINES

Provider Adjustment Amount -

Group


PIC S9(8)V99


Filler PIC X(8)

R 1--18

79 50

77 2Instruction to use TL - CR from OFM

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

50, 51, 72, AP, B2, B3,

BD, BN, C5, CS, CV,

DM, E3, FB, GO, HM,-03-1 Adjustment Reason Code

PIC X(2)ID 2--2

69 8


CCYYMMDD

Legacy in case of VA pricing

PLB02 Fiscal Period Date

05 Fiscal Period Date - Group PIC

X(8) DT 8--8

19 50NPI

1 18 1

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

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

Start Length

Record Repeat

CommentValues Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat


835 TR3 5010A1




22 30

3

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

19LQ01 Code List Qualifier Code PIC X(3) ID 1--3 HE

LQ 1 18 99215 2110LQ Health Care Remarks Codes 99 2110

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

18

AMT03 Credit/Debit Flag Code ID 1--1

22AMT02 Service Supplemental Amount05 Service Supplemental Amount -


19 3B6, KH, ZK, ZL, ZM, ZN, ZO

18 12

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

211 2110 AMT 1AMT Service Supplemental Amount 9 2110

-REF04

50 NCD/LCD code


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

19 30K

18 5

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

209 2110 REF 1REF Health Care Policy Identification 5 2110

-REF04

50


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

19 3HPI, SY, TJ, 1C, 1G

18 10

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

207 2110 REF 1REF Rendering Provider Information 10 2110

Comment

-REF04



Values Page #

Loop ID

Loop Seq

Element

Identifier

COBOL PIC

ID Min/Max Loop


835 TR3 5010A1




13

Attachment 1



835 TR3 5010A1

Usa

ge

Req

S

S

R

S

S

S

R

S

S

S

Usa

ge

Req

R

S

S

S

R

S

S

R

R

R

R

Usa

ge

Req

R

R

R

R

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

19 5Total functional groups (GS-GE pairs)

1 18 1

IEA01 # Included Functional GroupsPIC 9(5)

N0 1-5

IEAIEA Interchange Control Trailer 1 ----

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

19 6Total transaction sets (ST-SE pairs)

Start Length

Record Repeat

Comment

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

Values Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat


835 TR3 5010A1




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

29 9=ST02

10

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

19SE01 Transition Segment Count PIC 9(10) N0 1--10

SE 1 18 11 228SE Transaction Set Trailer 1 ----

479 18

50

PLB14 Provider Adjustment Amount05 Provider Adjustment Amount -


429



427 2

50, 51, 72, AP, B2, B3,

BD, BN, C5, CS, CV,

DM, E3, FB, GO, HM,

IP, IS, IR, J1, L3, L6,

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

-13-1 Adjustment Reason Code

PIC X(2)

ID 2--2


409 18

50



359



357 2

50, 51, 72, AP, B2, B3,

BD, BN, C5, CS, CV,

DM, E3, FB, GO, HM,

IP, IS, IR, J1, L3, L6,


Length

Record Repeat

Comment


PIC X(2)

ID 2--2

Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values


835 TR3 5010A1





339 18

50



289



287 2

50, 51, 72, AP, B2, B3,

BD, BN, C5, CS, CV,

DM, E3, FB, GO, HM,

IP, IS, IR, J1, L3, L6,



PIC X(2)

ID 2--2


269 18

50



219



217 2

50, 51, 72, AP, B2, B3,

BD, BN, C5, CS, CV,

DM, E3, FB, GO, HM,

IP, IS, IR, J1, L3, L6,



PIC X(2)

ID 2--2


199 18

Length

Record Repeat

Comment



Page #

Loop ID


Element

Identifier

COBOL PIC

ID Min/Max Loop

Loop Repeat

Values


835 TR3 5010A1

14

Attachment 1



835 TR3 5010A1

15

Documents

RECORD ONE FIELD NO. FIELD NAME PIC L/R FROM TO · PDF filerecord one field no. field name. pic l/r: from to: loop id segment: element rqmt: comments 1: intermediary number x10: l