ADDENDUM 2--HEALTH CARE PAYMENT AND REMITTANCE ADVICE
[Please label any written comments or e-mailed comments about this
section with the subject: Addendum 2]
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