Transcription
RECORD ONEFIELD NO. FIELD NAME1INTERMEDIARY NUMBERPICX10L/RL2PAYEE CHAIN ID NUMBERX15L345678PAYEE NUMBER/NPI (when effect)FISCAL PERIOD END (CCYYMMDD)FACILITY TYPE CODE (TT)PATIENT LAST NAMEINTERNAL CONTROL NUMBERREMITTANCE ADVICE INDICATORX159(8)X2X25X30X1LRLLLL910FILLERLINE SEQUENCE NUMBERX11X3LL11121314151617181920212223RECORD TYPECLAIM SEQUENCE NUMBERPRODUCTION / TEST INDICATOR (P or T)DATA INDICATORPAYEE PAYMENT AMOUNTDEBIT/CREDIT FLAG (C)PAYMENT METHOD CODEPAYMENT FORMAT CODE (CCP)SENDER DFI ID NUMBER QUALIFIER (01)FI BANK ID NUMBERACOUNT NUMBER QUALIFIER (DA)FI BANK ACCT NUMBERFEDERAL TAX IDENTIFICATION NO. andORIGINATING PAYER IDENTIFIERRECEIVER DFI ID NUMBER QUALIFIER (01)RECEIVING BANK ABA NO.PAYEE BANK ACCT NO QUALIFIERPAYEE BANK ACCT NUMBERCHECK/EFT/RA DATE (CCYYMMDD)TRACE TYPE CODE (1)CHECK/EFT TRACE NUMBERREMITTANCE ADVICE NUMBERPRODUCTION DATE QUALIFIER (405)PAYER CYCLE DATE (CCYYMMDD)ORIGINATING COMPANY RLLLRLLLLRLX119L2425262728293031323334354010 and 4010A1 835 ERAFlat File Spread SheetRecord 01FROM TO LOOP ID SEGMENT ELEMENT RQMT COMMENTS110HeaderISA06MPg. B.4HeaderGS02M1125HeaderISA08MPg. B.5HeaderGS03M264041484950517576105106 106This indicator will be set based ininformation in the financial master fileper provider.107 117118 120This line sequence number will beutilized to appropriately sequencerecords 50 and 51.121 122123 125126 126HeaderISA15MPg. B.6127 127HeaderBPR01MPg. 45128 138HeaderBPR02MPg. 46139 139HeaderBPR03MPg. 46140 142HeaderBPR04MPg. 46143 145HeaderBPR05SPg. 47146 147HeaderBPR06SPg. 48148 159HeaderBPR07SPg. 48160 161HeaderBPR08SPg. 48162 178HeaderBPR09SPg. 49Header BPR / TRN10 / 03S / R Pg. 49 and 53179 188189 190HeaderBPR12SPg. 49191 202HeaderBPR13SPg. 50203 205HeaderBPR14SPg. 50206 222HeaderBPR15SPg. 50223 230HeaderBPR16MPg. 50231 231HeaderTRN1MPg. 52232 246HeaderTRN2MPg. 53247 261HeaderTRN2MPg. 53262 264HeaderDTM1MPg. 60265 272HeaderDTM2MPg. 61273 281HeaderBPR/TRN11/04S/S Pg. 49 and 53312400Updated as of 5/2004cms0593251
RECORD TENFIELD NO. FIELD NAME1INTERMEDIARY NUMBER2PAYEE CHAIN ID NUMBER3PAYEE NUMBER/NPI (when effect)4FISCAL PERIOD END (CCYYMMDD)5FACILITY TYPE CODE (TT)6PATIENT LAST NAME7INTERNAL CONTROL NUMBER8REMITTANCE ADVICE INDICATOR9101112131415161718192021222324FILLERLINE SEQUENCE NUMBERRECORD TYPECLAIM SEQUENCE NUMBERPAYER ENTITY IDENTIFIER CODE (PRINTERMEDIARY NAMENATIONAL PLAN ID QUALIFIER (XV)NATIONAL PLAN IDPAYER ADDRESSADDITIONAL ADDRESS INFOPAYER CITYPAYER STATEPAYER ZIP CODEADDITIONAL PAYER IDENTIFICATIONQUALIFIER (2U)ADDITIONAL PAYER IDENTIFICATIONNUMBERFILLERUpdated as of 5/20044010 and 4010A1 835 ERAFlat File Spread SheetRecord 495176106TO102540485075105106LOOP IDSEGMENT ELEMENTRQMT N3N4N4N4REF01020304010201020301MSSSMSMMMMPg. 62Pg. 63Pg. 63Pg. 63Pg. 64Pg. 64Pg. 65Pg. 65Pg. 65Pg. 67X15L2782921000AREF02MPg. 68X108L293400This indicator will be set based ininformation in the financial master fileper provider.cms0593252
RECORD FIFTEENFIELD NO. FIELD NAME1INTERMEDIARY NUMBER2PAYEE CHAIN ID NUMBER3PAYEE NUMBER/NPI (when effect)4FISCAL PERIOD END (CCYYMMDD)5FACILITY TYPE CODE (TT)6PATIENT LAST NAME7INTERNAL CONTROL NUMBER8REMITTANCE ADVICE ERLINE SEQUENCE NUMBERRECORD TYPECLAIM SEQUENCE NUMBERPAYEE ENTITY CODE QUALIFIER (PE)PAYEE NAMEPAYEE ID QUALIFIER (FI / XX)PAYEE HCFA NPIPAYEE ADDRESSADDITIONAL ADDRESS INFOPAYEE CITYPAYEE STATEPAYEE ZIP CODEPAYEE COUNTRY CODEPAYEE ADDITIONAL ID QUALIFIER (TJ)PAYEE TAX ID NUMBERPAYEE ADDITIONAL ID QUALIFIER (PQ)MEDICARE PAYEE NUMBERFILLERUpdated as of 1651802152402652672762792812962983134010 and 4010A1 835 ERAFlat File Spread SheetRecord 15TOLOOP IDSEGMENT 401020102030401020102RQMT COMMENTSThis indicator will be set based ininformation in the financial master fileper provider.MSRMMSMMMSMMMMPg. 72Pg. 73Pg. 73Pg. 73Pg. 74Pg. 74Pg. 75Pg. 75Pg. 76Pg. 76Pg. 77Pg. 78Pg. 77Pg. 783
RECORD TWENTYFIELD NO. FIELD NAME1INTERMEDIARY NUMBER2PAYEE CHAIN ID NUMBER3PAYEE NUMBER/NPI (when effect)4FISCAL PERIOD END (CCYYMMDD)5FACILITY TYPE CODE (TT)6PATIENT LAST NAME7INTERNAL CONTROL NUMBER8REMITTANCE ADVICE 303132333435FILLERLINE SEQUENCE NUMBERRECORD TYPECLAIM SEQUENCE NUMBERASSIGNED NUMBER (TTYYMM) (SEENOTE)TOTAL CLAIM COUNTTOTAL SUBMTTED CHARGESTOTAL COVERED CHARGESTOTAL NON COVERED CHGSTOTAL DENIED CHARGESTOTAL PAYEE PAYMENTTOTAL INTEREST AMOUNTTOTAL CONTRACTUAL ADJ (A2)TOTAL GRH REDUCTIONTOTAL MSP PAYER AMTTOTAL BLOOD DEDUCTIBLETOTAL NON LAB CHRG AMTTOTAL COINSURANCE AMTTOTAL HCPCS RPT'D CHRGTOTAL HCPCS ALLOWABLE (FEE)TOTAL DEDUCTIBLE AMTTOTAL PROF COMP AMTTOTAL MSP PAT LIAB METTOTAL PATIENT REIMB AMTTOTAL PIP CLAIMS COUNTTOTAL PIP ADJ RL4010 and 4010A1 835 ERAFlat File Spread SheetRecord 20FROMTOLOOP ID SEGMENT ELEMENT RQMT COMMENTS110112526402000TS301MPg. 8141482000TS303MPg. 8149502000TS302MPg. 81517576105106106This indicator will be set based ininformation in the financial masterfile per . 31415161718192021222324MMSSSSSSSSSSSSSSSSSSSPg. 81Pg. 82Pg. 82Pg. 82Pg. 82Pg. 82Pg. 82Pg. 82Pg. 83Pg. 83Pg. 83Pg. 83Pg. 83Pg. 83Pg. 83Pg. 84Pg. 84Pg. 84Pg. 84Pg. 84Pg. 84NOTE: THE ASSIGNED NUMBER IS CONSTRUCTED AS FOLLOWS:THE FIRST TWO POSITIONS CONTAIN THE FACILITY CODE (TT)THE REMAINDER CONTAINS THE YEAR AND MONTH (YYMM)Updated as of 5/2004cms0593254
RECORD TWENTY-ONEFIELD NO. FIELD NAME1INTERMEDIARY NUMBER2PAYEE CHAIN ID NUMBER3PAYEE NUMBER/NPI (when effect)4FISCAL PERIOD END (CCYYMMDD)5FACILITY TYPE CODE (TT)6PATIENT LAST NAME7INTERNAL CONTROL NUMBER8REMITTANCE ADVICE E SEQUENCE NUMBERX311RECORD TYPEX212CLAIM SEQUENCE NUMBERX313TOTAL DRG AMOUNTS9(9)V9914TOTAL FED SPECIFIC AMTS9(9)V9915TOTAL HSP SPECIFIC AMTS9(9)V9916TOTAL DSH AMOUNTS9(9)V9917TOTAL CAPITAL AMOUNTS9(9)V9918TOTAL IME AMOUNTS9(9)V9919TOTAL OUTLIER DAY COUNT9(6)20TOTAL OUTLIER AMOUNTS9(9)V9921TOTAL COST OUTLIER AMTS9(9)V9922TOTAL AVG DRG LGNTH STAY9(6)23TOTAL DISCHARGE COUNT9(6)24TOTAL COST RPT DAY COUNT9(6)25TOTAL COVERED DAY COUNT9(6)26TOTAL N-CVD DAY COUNT9(6)27TOTAL MSP PASS THRU AMTS9(9)V9928AVERAGE DRG WEIGHTS9(3)V999929TOTAL PPS CAP FSP DRG AMTS9(9)V9930TOTAL PPS CAP HSP DRG AMTS9(9)V9931TOTAL PPS DSH DRG AMTS9(9)V9932FILLERX100NOTE: TS201 IS REQUIRED IF THE SEGMENT IS USED.Updated as of 5/2004L/RLLLRLLLLLLLLRRRRRRRRRRRRRRRRRRRL4010 and 4010A1 835 ERAFlat File Spread SheetRecord 21FROMTOLOOP ID TS2TS2TS2TS2TS2TS2TS2TS2TS2ELEMENT RQMT COMMENTSThis indicator will be set based ininformation in the financial master fileper SSSSSSSSSSSSSSSSPg. 86Pg. 86Pg. 86Pg. 86Pg. 86Pg. 87Pg. 87Pg. 87Pg. 87Pg. 87Pg. 87Pg. 87Pg. 88Pg. 88Pg. 88Pg. 88Pg. 88Pg. 88Pg. 885
RECORD THIRTYFIELD NO. FIELD NAME1INTERMEDIARY NUMBER2PAYEE CHAIN ID NUMBER3PAYEE NUMBER?NPI (when effect)4FISCAL PERIOD END (CCYYMMDD)5FACILITY TYPE CODE (TT)6PATIENT LAST NAME7INTERNAL CONTROL NUMBER8REMITTANCE ADVICE FILLERLINE SEQUENCE NUMBERRECORD TYPECLAIM SEQUENCE NUMBERPATIENT CONTROL NUMBERCLAIM STATUS CODECLAIM SUBMITTED CHARGESCLAIM REIMBURSEMENT AMTCLAIM FILING INDICATOR (MA)FACILITY TYPE CODE (1ST & 2NDPOSITION OF TOB)CLAIM FREQUENCY CODE (3RDPOSITION OF TOB)DRG CODEDRG WEIGHTDISCHARGE FRACTIONPIP INDICATORMSP INDICATORPER DIEM RATECAPITAL CODENON COVERED CHARGESDENIED CHARGESFILLERUpdated as of 5/20044010 and 4010A1 835 ERAFlat File Spread SheetRecord 30FROMTOLOOP ID EMENT RQMT COMMENTS07SPg. 93This indicator will be set based ininformation in the financial master fileper provider.CLPCLPCLPCLPCLPCLP010203040608MMMMMSPg. 89Pg. 90Pg. 91Pg. 91Pg. 92Pg. 932100CLP09SPg. 93210021002100CLPCLPCLP111213SSSPg. 93Pg. 93Pg. 94Used for the Standard Paper RemitUsed for the Standard Paper RemitUsed for the Standard Paper RemitUsed for the Standard Paper RemitUsed for the Standard Paper RemitUsed for the Standard Paper Remitcms0593256
RECORD THIRTY-ONENote: Record Repeat of 49.FIELD NO. FIELD NAME1INTERMEDIARY NUMBER2PAYEE CHAIN ID NUMBER3PAYEE NUMBER/NPI (when effect)4FISCAL PERIOD END (CCYYMMDD)5FACILITY TYPE CODE (TT)6PATIENT LAST NAME7INTERNAL CONTROL NUMBER8REMITTANCE ADVICE LINE SEQUENCE NUMBERRECORD TYPECLAIM SEQUENCE NUMBERCLAIM ADJ GROUP CODE - 1CLAIM ADJ REASON CODE -1ADJUSTMENT AMOUNT - 1ADJUSTMENT QUANTITY - 1CLAIM ADJ REASON CODE - 2ADJUSTMENT AMOUNT - 2ADJUSTMENT QUANTITY - 2CLAIM ADJ REASON CODE - 3ADJUSTMENT AMOUNT - 3ADJUSTMENT QUANTITY - 3CLAIM ADJ REASON CODE - 4ADJUSTMENT AMOUNT - 4ADJUSTMENT QUANTITY - 4CLAIM ADJ REASON CODE - 5ADJUSTMENT AMOUNT - 5ADJUSTMENT QUANTITY - 5CLAIM ADJ REASON CODE - 6ADJUSTMENT AMOUNT - 6ADJUSTMENT QUANTITY - 6CLAIM ADJ GROUP CODE - 2CLAIM ADJ REASON CODE - 1ADJUSTMENT AMOUNT - 1ADJUSTMENT QUANTITY - 1CLAIM ADJ REASON CODE - 2ADJUSTMENT AMOUNT - 2ADJUSTMENT QUANTITY - 2CLAIM ADJ REASON CODE - 3ADJUSTMENT AMOUNT - 3ADJUSTMENT QUANTITY - 3CLAIM ADJ REASON CODE - 4ADJUSTMENT AMOUNT - 4ADJUSTMENT QUANTITY - 4CLAIM ADJ REASON CODE - 5ADJUSTMENT AMOUNT - 5ADJUSTMENT QUANTITY - 5CLAIM ADJ REASON CODE - 6ADJUSTMENT AMOUNT - 6ADJUSTMENT QUANTITY - 6FILLERUpdated as of 5/20044010 and 4010A1 835 ERAFlat File Spread SheetRecord 4299302311316319328333400LOOP IDSEGMENTELEMENTRQMT COMMENTSThis indicator will be set based ininformation in the financial master fileper . 97Pg. 97Pg. 97Pg. 98Pg. 98Pg. 98Pg. 98Pg. 98Pg. 99Pg. 99Pg. 99Pg. 99Pg. 99Pg. 100Pg. 100Pg. 100Pg. 100Pg. 100Pg. 101Pg. 97Pg. 97Pg. 97Pg. 98Pg. 98Pg. 98Pg. 98Pg. 98Pg. 99Pg. 99Pg. 99Pg. 99Pg. 99Pg. 100Pg. 100Pg. 100Pg. 100Pg. 100Pg. 1017
RECORD FORTYFIELD NO. FIELD NAME1INTERMEDIARY NUMBER2PAYEE CHAIN ID NUMBER3PAYEE NUMBER/NPI (when effect)4FISCAL PERIOD END (CCYYMMDD)5FACILITY TYPE CODE (TT)6PATIENT LAST NAME7INTERNAL CONTROL NUMBER8REMITTANCE ADVICE INDICATOR9101112131415161718192021222324FILLERLINE SEQUENCE NUMBERRECORD TYPECLAIM SEQUENCE NUMBERPATIENT IDENTIFIER CODE (QC)PATIENT TYPE CODE (1)PATIENT LAST NAMEPATIENT FIRST NAMEPATIENT MIDDLE NAMEPATIENT # ID CODE (HN HIC)PATIENT IDENTIFIER (HIC #)CORRECTED PATIENT ID CODE (74)CORRECTED PATIENT ID ENTITY TYPE QUALIFIERPATIENT # ID CODE (C/NEW HIC) (C)CORRECTED PATIENT ID (HIC #)FILLERUpdated as of 5/20044010 and 4010A1 835 ERAFlat File Spread SheetRecord 9154169184186206209210212232400cms059325LOOP IDSEGMENT2100NM1ELEMENT RQMT COMMENTS03MThis indicator will be set based ininformation in the financial masterfile per 01020809MMMMSSSMMSSPg. 102Pg. 103Pg. 103Pg. 103Pg. 103Pg. 103Pg. 104Pg. 108Pg. 109Pg. 109Pg. 1108
RECORD FORTY-ONEFIELD NO. FIELD NAME1INTERMEDIARY NUMBER2PAYEE CHAIN ID NUMBER3PAYEE NUMBER/NPI (when effect)4FISCAL PERIOD END (CCYYMMDD)5FACILITY TYPE CODE (TT)6PATIENT LAST NAME7INTERNAL CONTROL NUMBER8REMITTANCE ADVICE INDICATORPICX10X15X159(8)X2X25X30X14010 and 4010A1 835 ERAFlat File Spread SheetRecord 41L/RFROMTOLOOP TELEMENT RQMT COMMENTSThis indicator will be set based ininformation in the financial masterfile per provider.91011121314151617FILLERLINE SEQUENCE NUMBERRECORD TYPECLAIM SEQUENCE NUMBERCOB NAME QUALIFIER (TT)COB ENTITY TYPE (2)COB CARRIER NAMECOB IDENTIFICATION NUMBER QUALIFIER (PI / XV)COB CARRIER ID D PRIORITY PAYER NAME QUALIFIER(PR) - 1X2L1811822100NM101MPg. 114Pg. 115Pg. 115Pg. 115Pg. 115, Default this field to 00 if anumber is not known.Pg. 11619CORRECTED PRIORITY PAYER NAME ENTITY TYPEQUALIFIER (2) - 1X1L1831832100NM102MPg. 11720CORRECTED PRIORITY PAYER NAME - 1CORRECTED PRIORITY PAYER NUMBERQUALIFIER (PI / XV) - 1CORRECTED PRIORITY PAYER NUMBER - 1X35L1842182100NM103MPg. 117X2X15LL21922122023521002100NM1NM10809MMPg. 117Pg. 117, Default this field to 00 if anumber is not known.23CORRECTED PRIORITY PAYER NAME QUALIFIER(PR) - 2X2L2362372100NM101MPg. 11624CORRECTED PRIORITY PAYER NAME ENTITY TYPEQUALIFIER (2) - 2X1L2382382100NM102MPg. 11725X35L2392732100NM103MPg. 1172627CORRECTED PRIORITY PAYER NAME - 2CORRECTED PRIORITY PAYER NUMBERQUALIFIER (PI/XV) - 2CORRECTED PRIORITY PAYER NUMBER - 2X2X15LL27427627529021002100NM1NM10809MMPg. 117Pg. 117, Default this field to 00 if anumber is not known.28FILLERX110L2914002122Note: Corrected Priority Payer information will be populated when a claim was submitted as primary and CWF returned it as secondaryUpdated as of 5/2004cms0593259
RECORD FORTY-TWOFIELD NO. FIELD NAME1INTERMEDIARY NUMBER2PAYEE CHAIN ID NUMBER3PAYEE NUMBER/NPI (when effect)4FISCAL PERIOD END (CCYYMMDD)5FACILITY TYPE CODE (TT)6PATIENT LAST NAME7INTERNAL CONTROL NUMBER8REMITTANCE ADVICE 3031323334353637FILLERLINE SEQUENCE NUMBERRECORD TYPECLAIM SEQUENCE NUMBERCOVERED DAYS/VISITS (VALUE ZEROESPPS OPERATING OUTLIERLIFETIME PSYCH DAY COUNTCLAIM DRG AMOUNTCLAIM PAYMENT REMARK CDCLAIM DSH AMOUNTCLAIM MSP PASS THRU AMTCLAIM PPS CAPITAL AMOUNTPPS CAPITAL FSP DRG AMTPPS CAPITAL HSP DRG AMTPPS CAPITAL DSH DRG AMTOLD CAPITAL AMOUNTPPS CAPITAL IME AMOUNTPPS OPER HSP SPEC DRG AMTCOST REPORT DAY COUNTPPS OPER FSP SPEC DRG AMTCLAIM PPS OUTLIER AMOUNTCLAIM INDIRECT TEACHINGNON PAY PROF COMP AMTCLAIM PAYMENT REMARK CDCLAIM PAYMENT REMARK CDCLAIM PAYMENT REMARK CDCLAIM PAYMENT REMARK CDPPS CAPITAL EXCEPTION AMTFILLERUpdated as of 5/20044010 and 4010A1 835 ERAFlat File Spread SheetRecord P IDSEGMENT ELEMENT RQMT COMMENTSThis indicator will be set based in informationin the financial master file per provider.2100MIA01RPg. 2021222324SSSSSSSSSSSSSSSSSSSSSSSPg. 119Pg. 119Pg. 120Pg. 120Pg. 120Pg. 120Pg. 120Pg. 120Pg. 120Pg. 121Pg. 121Pg. 121Pg. 121Pg. 121Pg. 121Pg. 121Pg. 122Pg. 122Pg. 122Pg. 122Pg. 122Pg. 122Pg. 122cms05932510
RECORD FORTY-THREEFIELD NO.FIELD NAME1INTERMEDIARY NUMBER2PAYEE CHAIN ID NUMBER3PAYEE NUMBER/NPI (when effect)4FISCAL PERIOD END (CCYYMMDD)5FACILITY TYPE CODE (TT)6PATIENT LAST NAME7INTERNAL CONTROL NUMBER8REMITTANCE ADVICE INDICATOR910111213141516171819202122FILLERLINE SEQUENCE NUMBERRECORD TYPECLAIM SEQUENCE NUMBERREIMBURSEMENT RATECLAIM HCPCS ALLOWED AMTCLAIM PAYMENT REMARK CDCLAIM PAYMENT REMARK CDCLAIM PAYMENT REMARK CDCLAIM PAYMENT REMARK CDCLAIM PAYMENT REMARK CDCLAIM ESRD PAYMENT AMTNON PAY PROF COMP AMTFILLERUpdated as of 5/20044010 and 4010A1 835 ERAFlat File Spread SheetRecord 125132141146151156161166175184400LOOP ID SEGMENT ELEMENTRQMTCOMMENTSThis indicator will be set based ininformation in the financial master fileper SSSSSSSSPg. 124Pg. 124Pg. 124Pg. 124Pg. 124Pg. 125Pg. 125Pg. 125Pg. 12511
RECORD FORTY-FOURFIELD NO. FIELD NAME1INTERMEDIARY NUMBER2PAYEE CHAIN ID NUMBER3PAYEE NUMBER/NPI (when effect)4FISCAL PERIOD END (CCYYMMDD)5FACILITY TYPE CODE (TT)6PATIENT LAST NAME7INTERNAL CONTROL NUMBER8REMITTANCE ADVICE 8)X2X25X30X1FILLERX11LINE SEQUENCE NUMBERX3RECORD TYPEX2CLAIM SEQUENCE NUMBERX3MEDICAL RECORD NUMBER QUALIFIER (EA)X2MEDICAL RECORD NUMBERX25CLAIM RECEIVED DATE QUALIFIER (050)X3CLAIM RECEIVED DATE (CCYYMMDD)9(8)CLAIM STMNT START DATE QUALIFIER (232)X3CLAIM STATEMENT START DATE (CCYYMMDD)9(8)CLAIM STMNT END DATE QUALIFIER (233)X3CLAIM STATEMENT END DATE (CCYYMMDD)9(8)PER DIEM AMT I/P ONLY QUALIFIER (DY)X2PER DIEM AMT INPATIENT ONLYS9(7)V99NEGATIVE REIMBURSEMENT QUALIFIER (NL)X2NEGATIVE REIMBURSEMENTS9(7)V99HEMOPHILIA ADD-ON AMT QUALIFIER (ZK)X2HEMOPHILIA ADD-ON AMOUNTS9(7)V99PATIENT PAID AMOUNT QUALIFIER (F5)X2PATIENT PAID AMOUNTS9(7)V99INTEREST AMOUNT QUALIFIER (I)X1INTEREST AMOUNTS9(7)V99OUTLIER AMOUNT QUALIFIER (ZZ)X2OUTLIER AMOUNTS9(7)V99TOTAL COVERED CHARGES QUALIFIER (AU)X2TOTAL COVERED CHARGESS9(7)V99NEW TECHNOLOGY ADD-ON AMT QUALIFIER (Z X(2)NEW TECHNOLOGY ADD-ON AMOUNTS9(7)V99COVERED DAYS QUALIFIER (CA)X2COVERED DAYSS9(3)NON COVERED DAYS QUALIFIER (NA)X2NON COVERED DAYSS9(4)LIFE TIME RESERVED DAYS QUALIFIER (LA)X2LIFE TIME RESERVED DAYSS9(3)COINSURANCE DAYS QUALIFIER (CD)X2COINSURANCE DAYSS9(3)HEMOPHILIA ADD-ON UNITS QUALFIER (ZK)X2HEMOPHILIA ADD-ON UNITSS9(7)OUTLIER DAYS QUALIFIER (OU)X2Updated as of RLRLRL4010 and 4010A1 835 ERAFlat File Spread SheetRecord 44FROMTOLOOP YQTYQTYQTYQTYQTYQTYQTYQTYQTYQTYELEMENTRQMT COMMENTSThis indicator will be set based ininformation in the financial masterfile per RRRRRRRRRRRRRRPg. 126Pg. 127Pg. 131Pg. 131Pg. 131Pg. 131Pg. 131Pg. 131Pg. 135Pg. 136Pg. 135Pg. 136Pg. 135Pg. 136Pg. 135Pg. 136Pg. 135Pg. 136Pg. 135Pg. 136Pg. 135Pg. 136Pg. 135Pg. 136Pg. 137Pg. 138Pg. 137Pg. 138Pg. 137Pg. 138Pg. 137Pg. 138Pg. 137Pg. 138Pg. 13712
4010 and 4010A1 835 ERAFlat File Spread SheetRecord 50RECORD FIFTYNote: Record Repeat of 999FIELD NO. FIELD NAME1INTERMEDIARY NUMBER2PAYEE CHAIN ID NUMBER3PAYEE NUMBER/NPI (when effect)4FISCAL PERIOD END (CCYYMMDD)5FACILITY TYPE CODE (TT)6PATIENT LAST NAME7INTERNAL CONTROL NUMBER8REMITTANCE ADVICE 3031323334353637383940414243FILLERLINE SEQUENCE NUMBERRECORD TYPECLAIM SEQUENCE NUMBERPROCESSED HCPC CODE QUALIFIER(HC/NU/ZZ)PROCESSED REVENUE/HCPC/HIPPS CODEPROCESSED NDC CODE QUALIFIER (N4)PROCESSED NDC CODEPROCESSED MODIFIERPROCESSED MODIFIERPROCESSED MODIFIERPROCESSED MODIFIERSUBMITTED CHARGESLINE ITEM PAID AMOUNTREVENUE CODECOVERED UNITSSUBMITTED HCPC CODE QUALIFIER (HC)SUBMITTED HCPC CODESUBMITTED NDC CODE QUALIFIER (N4)SUBMITTED NDC CODESUBMITTED MODIFIERSUBMITTED MODIFIERSUBMITTED MODIFIERSUBMITTED MODIFIERSUBMITTED UNITS OF SERVICESERVICE DATE QUALIFIER (472)SERVICE DATE (CCYYMMDD)ASC/APC/HIPPS NUMBER QUALIFIER (1S/RB)ASC/APC/HIPPS NUMBERASC/HIPPS RATEPER DIEM AMOUNT QUALIFIER (DY)PER DIEM AMOUNTACTUAL ALLOWED (includingASC/APC/HIPPS) AMOUNT QUALIFIER (B6)ACTUAL ALLOWED (includingASC/APC/HIPPS) AMOUNTREMARKS CODE QUALIFIER (HE)Updated as of 2641495176106TO102540485075105106LOOP IDSEGMENT 1171201221251272110SVC01-1MPg. 70102010202010201MMMSSSSMMSSMMMMSSSSSMMMMMMMMPg. 141Pg. 140Pg. 141Pg. 141Pg. 141Pg. 141Pg. 141Pg. 142Pg. 142Pg. 142Pg. 142Pg. 143Pg. 144Pg. 143Pg. 144Pg. 144Pg. 144Pg. 144Pg. 144Pg. 145Pg. 147Pg. 147Pg. 154Pg. 155Pg. 155Pg. 158Pg. 159Pg. 158S9(7)V99R2702782110AMT02MPg. 159X2L2792802110LQ01MPg. 162This indicator will be set based ininformation in the financial master fileper provider.cms05932513
RECORD FIFTYNote: Record Repeat of 999FIELD NO. FIELD NAME44REF REMARK CODE 145REMARKS CODE QUALIFIER (HE)46REF REMARK CODE 247REMARKS CODE QUALIFIER (HE)48REF REMARK CODE 349REMARKS CODE QUALIFIER (HE)50REF REMARK CODE 451REMARKS CODE QUALIFIER (HE)52REF REMARK CODE 553REMARKS CODE QUALIFIER (HE)54REF REMARK CODE 655REMARKS CODE QUALIFIER (HE)56REF REMARK CODE 757REMARKS CODE QUALIFIER (HE)58REF REMARK CODE 859REMARKS CODE QUALIFIER (HE)60REF REMARK CODE 961FILLERUpdated as of 5/20044010 and 4010A1 835 ERAFlat File Spread SheetRecord 315320322327329334336341400LOOP 21102110211021102110cms059325SEGMENT ENTSPg. 163Pg. 162Pg. 163Pg. 162Pg. 163Pg. 162Pg. 163Pg. 162Pg. 163Pg. 162Pg. 163Pg. 162Pg. 163Pg. 162Pg. 163Pg. 162Pg. 16314
RECORD FIFTY-ONE Line Level CASNote: Record Repeat of 99FIELD NO. FIELD NAME1INTERMEDIARY NUMBER2PAYEE CHAIN ID NUMBER3PAYEE NUMBER/NPI (when effect)4FISCAL PERIOD END (CCYYMMDD)5FACILITY TYPE CODE (TT)6PATIENT LAST NAME7INTERNAL CONTROL NUMBER8REMITTANCE ADVICE 303132FILLERLINE SEQUENCE NUMBERRECORD TYPECLAIM SEQUENCE NUMBERGROUP CODELINE ADJ REASON CODE - 1ADJUSTMENT AMOUNT - 1ADJUSTMENT QUANTITY - 1LINE ADJ REASON CODE - 2ADJUSTMENT AMOUNT - 2ADJUSTMENT QUANTITY - 2LINE ADJ REASON CODE - 3ADJUSTMENT AMOUNT - 3ADJUSTMENT QUANTITY - 3LINE ADJ REASON CODE - 4ADJUSTMENT AMOUNT - 4ADJUSTMENT QUANTITY - 4LINE ADJ REASON CODE - 5ADJUSTMENT AMOUNT - 5ADJUSTMENT QUANTITY - 5LINE ADJ REASON CODE - 6ADJUSTMENT AMOUNT - 6ADJUSTMENT QUANTITY - 6FILLERUpdated as of 5/20044010 and 4010A1 835 ERAFlat File Spread SheetRecord 00LOOP IDSEGMENT ELEMENT RQMT COMMENTSThis indicator will be set based ininformation in the financial masterfile per SSSSSSSSPg. 150Pg. 150Pg. 150Pg. 150Pg. 151Pg. 151Pg. 151Pg. 151Pg. 151Pg. 152Pg. 152Pg. 152Pg. 152Pg. 152Pg. 153Pg. 153Pg. 153Pg. 153Pg. 15315
RECORD SIXTYNote: Repeat Greater than OneFIELD NO. FIELD NAME1INTERMEDIARY NUMBER2PAYEE CHAIN ID NUMBER3PAYEE NUMBER/NPI (when effect)4FISCAL PERIOD END (CCYYMMDD)5FACILITY TYPE CODE (TT)6PATIENT LAST NAME7INTERNAL CONTROL NUMBER8REMITTANCE ADVICE 303132FILLERLINE SEQUENCE NUMBERRECORD TYPECLAIM SEQUENCE NUMBERPAYEE ADJ REASON CODE - 1PAYEE ADJ IDENTIFIER CD - 1PAYEE ADJ AMOUNT - 1PAYEE ADJ REASON CODE - 2PAYEE ADJ IDENTIFIER CD - 2PAYEE ADJ AMOUNT - 2PAYEE ADJ REASON CODE - 3PAYEE ADJ IDENTIFIER CD - 3PAYEE ADJ AMOUNT - 3PAYEE ADJ REASON CODE - 4PAYEE ADJ IDENTIFIER CD - 4PAYEE ADJ AMOUNT - 4PAYEE ADJ REASON CODE - 5PAYEE ADJ IDENTIFIER CD - 5PAYEE ADJ AMOUNT - 5PAYEE ADJ REASON CODE - 6PAYEE ADJ IDENTIFIER CD - 6PAYEE ADJ AMOUNT - 6Claim A/R Adjustment for BalancingFILLERUpdated as of LRLLRLLRRL4010 and 4010A1 835 ERAFlat File Spread SheetFROMTO RecordLOOP60ID SEGMENT ELEMENT RQMT COMMENTS11011252640SummaryPLB01MPg. 1654148SummaryPLB02MPg. 1654950517576105106106This indicator will be set based ininformation in the financial masterfile per 3-1MPg. 165 - 170128132SummaryPLB03-2SPg. 165 - 170133143SummaryPLB4MPg. 170144145SummaryPLB05-1SPg. 170146150SummaryPLB05-2SPg. 170151161SummaryPLB06SPg. 170162163SummaryPLB07-1SPg. 171164168SummaryPLB07-2SPg. 171169179SummaryPLB08SPg. 171180181SummaryPLB09-1SPg. 171182186SummaryPLB09-2SPg. 171187197SummaryPLB10SPg. 171198199SummaryPLB11-1SPg. 171200204SummaryPLB11-2SPg. 172205215SummaryPLB12SPg. 172216217SummaryPLB13-1SPg. 172218222SummaryPLB13-2SPg. 172223233SummaryPLB14SPg. 172234244User for Standard Paper Remit245400cms05932516
RECORD NINETY-NINEFIELD NO. FIELD NAME1INTERMEDIARY NUMBER2PAYEE CHAIN ID NUMBER3PAYEE NUMBER/NPI (when effect)4FISCAL PERIOD END (CCYYMMDD)5FACILITY TYPE CODE (TT)6PATIENT LAST NAME7INTERNAL CONTROL NUMBER8REMITTANCE ADVICE INDICATOR91011121314151617181920FILLERLINE SEQUENCE NUMBERRECORD TYPECLAIM SEQUENCE NUMBERTOTAL PAYEE IN CHAINTOTAL RECORDS IN CHAINTOTAL PROV CHAIN PYMT TOTALPAYEE CHAIN ID NUMBERINTERCHANGE CONTROL NUMBERTOTAL RECORDS IN FILETOTAL PAYEE CHAINS IN FILEFILLERUpdated as of 4010 and 4010A1 835 ERAFlat File Spread SheetRecord 99FROMTOLOOP ID SEGMENT ELEMENT RQMT COMMENTS1101125264041484950517576105106106This indicator will be set based ininformation in the financial masterfile per 8159173174182183194195198199400cms05932517
4010 and 4010a1 835 era flat file spread sheet record twenty record 20 field no. field name pic l/r from to loop id segment element rqmt comments 1 intermediary number x10 l 1 10 2 payee chain id number x15 l 11 25 3 payee number/npi (when effect) x15 l 26 40 2000 ts3 01 m pg. 81 4 fiscal period end (ccyymmdd) 9(8) r 41 48 2000 ts3 03 m pg. 81
