[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

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


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