ADDENDUM 2--HEALTH CARE PAYMENT AND REMITTANCE ADVICE

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The transaction selected for the health care payment and remittance advice is ASC X12N 835 - Health Care Claim Payment/Advice (004010X091).

A. Implementation Guide and Source

The source of the implementation guide for the ASC X12N 835 - Health Care Claim Payment/Advice (004010X091) is: Washington Publishing Company, 806 W. Diamond Ave., Suite 400, Gaithersburg, MD, 20878, Telephone 301-590-9337, FAX: 301-869-9460. The website address is http://www.wpc-edi.com/hipaa/

B. Data Elements

Account Number Qualifier
Additional Payee Identifier
Adjustment Amount
Adjustment Quantity
Adjustment Reason Code
Amount Paid to Patient
Amount Qualifier Code
Assigned Number
Average DRG length of stay
Average DRG weight
Century
Check or EFT Trace Number
Check/EFT Issue Date
Claim Adjustment Group Code
Claim Contact Communications Number
Claim Contact Name
Claim Date
Claim Disproportionate Share Amount
Claim ESRD Payment Amount
Claim Filing Indicator Code
Claim Frequency Code
Claim HCPCS payable amount
Claim Indirect Teaching Amount
Claim MSP Pass-through amount
Claim Payment Remark Code
Claim PPS capital amount
Claim PPS capital outlier amount
Claim Status Code
Claim Supplemental Information Amount
Claim Supplemental Information Quantity
Code List Qualifier Code
Communication Number Extension
Communication Number Qualifier
Contact Function Code
Corrected Insured Identification Indicator
Corrected Patient or Insured First Name
Corrected Patient or Insured Last Name
Corrected Patient or Insured Middle Name
Corrected Patient or Insured Name Prefix
Corrected Patient or Insured Name Suffix
Corrected Priority Payer Identification Number
Corrected Priority Payer Name
Cost Report Day Count
Covered Days or Visits Count
Credit/Debit Flag Code
Crossover Carrier Identifier
Crossover Carrier Name
Currency Code
Date/Time Qualifier
Depository Financial Institution (DFI) Identifier
Depository Financial Institution (DFI) ID Number Qualifier
Description Text
Diagnosis Related Group (DRG) Weight
Diagnosis Related Group (DRG)
Discharge Fraction
Entity Identifier Code
Entity Type Qualifier
Exchange Rate
Facility Type Code
Fiscal Period Date
Identification Code Qualifier
Lifetime Psychiatric Days Count
Line Item Provider Payment Amount
Location Identification Code
Location Qualifier
National Uniform Billing Committee Revenue Code
Old Capital Amount
Original Service Unit Count
Originating Company Supplemental Code
Other Claim Related Identifier
Patient Control Number
Patient First Name
Patient Last Name
Patient Liability Amount
Patient Middle Name
Patient Name Prefix
Patient Name Suffix
Patient Status Code
Payee City Name
Payee First Line Address
Payee Identification Code
Payee Name
Payee Postal Zip Code
Payee Second Line Address
Payee State Code
Payer City Name
Payer Claim Control Number
Payer Contact Communication Number
Payer Contact Name
Payer First Address Line
Payer Identifier
Payer Name
Payer Process Date
Payer Second Address Line
Payer State Code
Payer ZIP Code
Payment Format Code
Payment Method Code
Procedure Modifier
Product/Service ID Qualifier
Product/Service Procedure Code Text
Product/Service Procedure Code
Production Date
Professional Component Amount
Provider Adjustment Amount
Provider Adjustment Identifier
Provider First Name
Provider Identifier
Provider Last or Organization Name
Provider Middle Name
Provider Name Prefix
Provider Name Suffix
PPS-Capital DSH DRG Amount
PPS-Capital Exception Amount
PPS-Capital FSP DRG Amount
PPS-Capital HSP DRG Amount
PPS-Capital IME amount
PPS-Operating Federal Specific DRG Amount
PPS-Operating Hospital Specific DRG Amount
Quantity Qualifier
Receiver or Provider Account Number
Receiver Identifier
Receiver/Provider Bank ID Number
Reference Identification Qualifier
Reimbursement Rate
Remark Code
Sender Account Number
Sender DFI Identifier
Service Date
Service Supplemental Amount
Service Supplemental Quantity Count
Submitted Charge Amount
Submitted Line Charges Paid
Subscriber First Name
Subscriber Identifier
Subscriber Last Name
Subscriber Middle Name
Subscriber Name Prefix
Subscriber Name Suffix
Total Actual Provider Payment Amount
Total Blood Deductible
Total Capital Amount
Total Claim Charge Amount
Total Claim Count
Total Coinsurance Amount
Total Contractual Adjustment Amount
Total Cost Outlier Amount
Total Cost Report Day Count
Total Covered Charge Amount
Total Covered Day Count
Total Day Outlier Amount
Total Deductible Amount
Total Denied Charge Amount
Total Discharge Count
Total Disp. Share Amount
Total DRG Amount
Total Federal-Specific Amount
Total Gramm-Rudman Reduction Amount
Total Hospital-Specific Amount
Total HCPCS Payable Amount
Total HCPCS Reported Charge Amount
Total Indirect Medical Education Amount
Total Interest Amount
Total MSP Pass-Through Amount
Total MSP Patient Liability Met Amount
Total MSP Payer Amount
Total Non-Covered Charge Amount
Total Non-Lab Charge Amount
Total Noncovered Charge Amount
Total Noncovered Day Count
Total Outlier Day Count
Total Patient Reimbursement Amount
Total Professional Component Amount
Total Provider Payment Amount
Total PIP Adjustment Amount
Total PIP Claim Count
Total PPS Capital FSP DRG Amount
Total PPS Capital HSP DRG Amount
Total PPS DSH DRG Amount
Trace Type Code
Transaction Handling Code
Transaction Segment Count
Transaction Set Control Number
Transaction Set Identifier Code
Units of Service Paid Count
Version Identifier