835 005010 Companion Guide
The Remittance Detail element is optional in Payment Remittance Request. If present it can repeat and provides a
breakdown of the payment showing how it is to be applied to invoices, purchase orders, or master agreements. Each
Remittance Detail can specify any combination of those three. That is, it can specify an invoice and a purchase order, the
presumption being that the two are related
Each Remittance Detail group maps onto one RMR group. In RMR, the first of invoice / purchase order / master
agreement is specified in RMR01-02. If additional documents are specified, they are written to REF segments
The TRN segment is used to uniquely identify a payment order/remittance advice.
The N1 loop allows for name/address information for the payer and payee which would be utilized to address
remittance(s) for delivery.
Loop RMR is for open items being referenced or for payment on account.
This ADX loop can only contain adjustment information for the immediately preceding RMR segment and affects
the amount (RMR04) calculation. If this adjustment amount is not netted to the immediately preceding RMR, use the
outer ADX loop (position 080).
ISA*00* *00* *ZZ*NDC STD REMIT *ZZ*07366.399173.W *200726*0027*|*00501*163939198*0*P*>
~GS*HP*NDC STD REMIT*1942272414*20200726*0027*128*X*005010X221A1
~ST*835*0128
~BPR*I*13488.09*C*ACH*CCP*01*20791*DA*5163013830*1630103830**01*021000018*DA*8900673346*20200730
~TRN*1*215028000420791*1630103830
~N1*PR*BLUE CROSS BLUE SHIELD OF ALABAMA*XV*X03 (Start of Loop ID 1000A- Payer Identification Loop)
~N3*450 RIVERCHASE PARKWAY EAST
~N4*BIRMINGHAM*AL*352020000
~REF*2U*00010
~PER*CX**TE*8772317239
~PER*BL*PROVIDER ESOLUTIONS*TE*2052206899*EM*ASK-EDI@BCBSAL.ORG
~N1*PE*DVA HEALTHCARE RENAL CARE INC*XX*1942272414 (Start of Loop ID 1000B- Payee Identification Loop)
~N3*PO BOX 402946
~N4*ATLANTA*GA*303842946
~REF*TJ*952977916
~REF*PQ*1942272414
~LX*2 (Start of Loop ID 2000- Header Number Loop)
~CLP*116101627101*1*21120.9*3360**12*7002054921*72*1 (Start of Loop ID 2100- Claim Pymt Information Loop)
~CAS*CO*45*17760.9
~NM1*QC*1*MOORE*ABBOTT****MI*PPA863258472
~NM1*74*1***L
~REF*LU*010218
~DTM*232*20200716
~DTM*233*20200721
~AMT*AU*21120.9
~AMT*I*.24
~CLP*115637830101*1*27299.4*4480**12*7001545913*72*1
~CAS*CO*45*22819.4
~NM1*QC*1*SLEDGE*BARBARA*K***MI*UQKAN8025231
~NM1*74*1**ANGELI
~REF*LU*010218
~DTM*232*20200522
~DTM*233*20200529
~AMT*AU*27299.4
~AMT*I*.24
~LX*3
----- SVC|DTM|CAS|REF|AMT|LQ – (Loop ID 2110- Service Payment Information)
----- PLB|SE – (Loop ID 0000- Transaction Set Loop (Summary))
----- GE|IEA – (Functional Group Loop (End))
ISA Interchange Identity
~ISA*00* *00* *01*048463400P *01*129552795ST *220621*0537*U*00501*000004731*0*P*>
ISA01 – Authorization Code Qualifier – 00
ISA02 – Authorization Code – blank
ISA03 - Security Code Qualifier – 00
ISA04 – Security Code – blank
ISA05 – Sender ID Qualifier – ZZ
ISA06 – Sender Identifier –
ISA07 – Receiver ID Qualifier – 01 (Your Identifier)
ISA08 – Receiver Identifier – 129552795ST (Your Identifier)
ISA09 – Interchange Date – YYMMDD
ISA10 – Interchange Time – HHMM
ISA11 – Control Standards Identifier – U
ISA12 – ANSI Version – 00401 or 00501
ISA13 – Interchange Control Number – Unique Control No
ISA14 – Acknowledgement Requested
o 0 (interchanges are not acknowledged)
o 1 (Acknowledgement Requested)
ISA15 – Test Indicator – P (Production Data) or T (Test)
ISA16 – Sub-element Separator - > (suggested)
GS - Functional Group Identity
~GS*RA*048463400P*953372911*20220621*0537*408985*X*005010
GS01 – Functional Group Identifier – RA
o HP = Health Care Claim Payment Advise
GS02- Application Sender
o Buyers Network ID
GS03 – Application Receiver
o DaVita’s Value – Federal Tax ID (Center Provider #)
GS04 – Functional Group Date CCYYMMDD
GS05 – Functional Group Time HHMM
GA06 – Functional Group Control No
o Unique Control No
GA07 – Agency
o X = Accredited Standards Committee X12
GA08 – Version
o 004010 or 005010 (005010X221A1)
ST Transaction Set Header
Header – Mandatory
Indicates the start of a transaction set and to assign a control number
~ST*835*0128
ST01 – Transaction Set Identifier Code
o 820 – Payment/Order/Remittance Advise
o 835 - Remittance
ST02 – Transaction Set Control Number
BPR Beginning Segment for Payment Order/Remittance Advice – Financial Information
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
~BPR*I*18518*C*ACH*CCP*01*221172186***A046002284**01*031000503*DA*2000076112962*20220621
BPR01 – Transaction Handling Code
o I - Remittance Information Only
o H - Notification Only
o C- Payment Accompanies Remittance Advice
o D – Make Payment Only
o P – Prenotification of Future Transfers
o U – Split Payment and Remittance
o X – Handling Party’s Option to Split Payment and Remittance
BPR02 – Monetary Amount/Total Actual Provider Payment Amount
BPR03 – Credit/Debit Flag Code
o C – Credit
o D – Does not apply to Medicare
o E – Indicates a Debit/Credit Advice with Remittance Detail
BPR04 – Payment Method Code
o ACH – Automated Clearing House
o CHK – Check
o NON – Non-Payment Data
o ZZZ - Other
BPR06 – ID Number Qualifier
o 01 – ABA Transit Routing Number Including Check Digits (9 digits)
BPR07 – Depository Financial Intuition (DFI) ID Number
BPR08 – Account Number Qualifier
BPR09 – Account Number
BPR12 – DFI IS Number Qualifier
o 01 – ABA Transit Routing Number including Check Digits (9 digits)
BPR13 – DFI Identification Number
BPR14 – Account Number Qualifier
BPR15 – Account Number
BPR16 – Date
o Date payment or remittance transaction was created CCYYMMDD
TRN Trace/Reassociation Trace Number
Uniquely identify a transaction to an application
~TRN*1*0000168I2011077*1046002284*105143726
TRN01 – Trace Type Code
o 1 – Current Transaction Trace Numbers
TRN02 – Reference Identification/Check Number/EFT Trace Number
o Unique identifier for this Payment Remittance, generated by the buying organization’s system
TRN03 – Identifies an organization/Originating Company Identifier
TRN04 – further subdivision within the organization
N1 Payer Identification - Name
Identify a party by type or organization, name and code
~N1*PR*COMM OF MASS**xxx
N101 – Payer Entity Identifier Code
o O1 – Originating bank
o PE – Payee
o PR – Payer
o RB – Receiving Bank
N102 – Payer Name
N103 – Identification Code Qualifier
o XX – Health Care Financing Admin National Provider Identifier (NPI)
o FI – Federal Taxpayer’s Identification Number (FEIN)
o XV – Centers for Medicare & Medicaid Services Plan ID
N104 – Identification Code – (Payer National Plan ID)
o Health Care Financing Admin National Provider Identifier (NPI) if available
N3 Address Information
~N3*PO BOX 149971
N301 – Address Information
N302 – Address Information
N4 Geographic Location
~N4*****BS*AUSTIN, TX 78714
N401 – City Name
N402 – State or Province Code
N403 – Postal Code
N404 – Country Code
REF Reference Identification
To specify identification information – Loop: N1
The four bank related references are copied to BPR06-07 and BPR12-13 depending on
the Contact@role being "originatingBank" or "receivingBank".
The two-bank account related references are copied to BPR09 and BPR15 depending on
the Contact@role being "payer" or "payee".
~REF*2U*00010
REF01 – Additional Payee Identification Qualifier
o 01 - American Bankers Assoc (ABA) Transit/Routing Number
o 03 – Clearing House Interbank Payment System (CHIPS)
o PB- Payer’s Financial Institution Account Number for Check, Draft or Wire Payments; Originating
Company Account Number for ACH Transfers
o PQ – Payee Identification
o PY – Payee’s Financial Institution Account Number for Check, Draft or Wire Payments: Receiving
Company Account Number for ACH Transfers
o TJ – Federal Taxpayer Id Number
o 2U – Payer Identification Number
o EO – Submitter Identification Number
o EV – Receiver ID Number
o HI – Health Industry Number (HIN)
o NF – National Association of Insurance Commissioners (NAIC) Code
REF02 – Reference Identification – EDI Submitter # (Payer ID)
o Trading Partner ID Assigned by Payer
o EDI Submitter Number (Payer ID) - Payee’s Provider ID
Ex. United Healthcare – 87726 / BCAL - 00010
PER Payer Contact Information/Administrative Communications Contact
Identify a person or office to whom administrative communication should be directed to
~PER*IC*VENDR-INQUIRY*TE*( 877 ) 353 – 9791
PER01 – Contact Function Code
o CX = Payers Claim Office
PER02 – Name/Claims Department
PER03 – Communication Number Qualifier
o TE = Telephone
o EX = Telephone Extension
o EM = Electronic Mail
o FX = Facsimile
PER04 – Communication Number/Phone Number
Payer Technical Contact Information
PER01 – Contact Function Code
o BL
PER02 – Payer Technical Contact Name
o EDI Support
PER03 – Communication Number Qualifier
o TE = Telephone
o EX = Telephone Extension
o EM = Electronic Mail
o FX = Facsimile
PER04 – Communication Number/Phone Number
PER05 – Payer Contact Communication Number
o EM = Electronic Mail
PER06 – Payer Technical Contact Communication
o EDI@ ……
Payer Web Site
PER01 – Contact Function Code
o IC – Information Contact
PER02 – Name/Claims Department
PER03 – Communication Number Qualifier
o UR – Uniform Resource Locator (URL)
PER04 – Communication URL
o www.xxxxxxx.com
N1 Payee Identification Loop
Identify a party by type or organization, name and code
~N1*PE*PHYSICIANS DIALYSIS AC*ZZ*VC6000189583
N101 – Payer Entity Identifier Code
o O1 – Originating bank
o PE – Payee
o PR – Payer
o RB – Receiving Bank
N102 – Payee Name
N103 – Identification Code Qualifier
o FI – Federal Taxpayer’s ID Number
o XV – Centers for Medicare & Medicaid Services Plan ID
o XX – Centers for Medicare & Medicaid services National Provider Id
N104 – Identification Code
o Center NPI # for some payers
o Payee Identification Code
LX Header Number
Required when claim or service level information follows
~LX*2
LX01 – Claim Sequence Number – Transaction Sequence Number
*************************************************************************************************
CLP – Claim Payment Information (Loop 2100)
To supply information common to all services of a claim
CLP*259532-4443467*2*2277.64*455.53**MC*5035675603**7
CLP01 = 259532-4443467
Claim Submitter’s Identifier – Identifier used to track a claim from creation by the health care provider through
payment.
CLP02 = 2
Claim Status Code – Code identifying the status of an entire claim as assigned by the payor. 1/Primary
2/Secondary 3/Tertiary 4/Denied 22/Reversal of previous payment
CLP03 = 2277.64
Monetary Amount – Is the amount of submitted charges for this claim.
CLP04 = 455.53
Monetary Amount – Is the amount paid for this claim.
CLP06 = MC
Claim Filing Indicator Code – Code identifying type of claim. MC = Medicaid
CLP07 = 5035675603
Reference Identification – ICN #
SVC – Service Payment Information (Loop 2110)
To supply payment and control information to a provider for a particular service
SVC*HC:J0636*13.8*2.9*10~
SVC01 = HC
Product/Service ID Qualifier – Code identifying the type/service of the descriptive number used in
product/service ID. HC= HCFA common procedural coding system (HCPCS) codes.
SVC01-2 = J0636
Product/Service ID – Identifying number for a product or service.
SCV02 = 13.8
Monetary Amount – The submitted service charge. (Line item charge amount)
SCV03 = 2.9
Monetary Amount – The amount paid for this service.
SCV05 = 10
Quantity – Numeric value of quantity. The paid units of service.
CAS – Claim Adjustment (Loop 2100)
To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service
within the claim being paid.
CAS*CO*23*10.9
CAS01 = CO
Claim Adjustment Group Code – Code identifying the general category of payment adjustments.
CO/Contractual Obligations CR/Correction & Reversals OA/Other Adjustments PI/Payor Initiated
Reductions
CAS02 = 23
Claim Adjustment Reason Code – Code identifying the detailed reason the adjustment was made.
CAS03 = 10.9
Monetary Amount – This is the amount of the adjustment.
