835 Flat File - 5010A1

UPDATED 2/27/2018
835 TR3 5010A1

Legend: Changed field highlighted in yellow

X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18

Element COBOL PIC ID Min/Max Usa Loop Loop Repeat Values Page # Loop ID Loop Seq Seg ID Seg. Seq. Start Length Record Repeat Comment
6 4 4 4
ISA Interchange Control Header 1 405 -------- ISA 1 18 1
ISA01 Authorization Information Qualifier PIC X(2) ID 2--2 R 00 19 2
ISA02 Authorization Information PIC X(10) AN 10--10 R Blank 21 10
ISA03 Security Information Qualifier PIC X(2) ID 2--2 R 00 31 2
ISA04 Security Information PIC X(10) AN 10--10 R Blank 33 10
01,14,20,27,28,
ISA05 PIC X(2) ID 2--2 R 43 2
29,30,33,ZZ
Interchange ID Qualifier
ISA06 Interchange Sender ID PIC X(15) AN 15--15 R Interchange Sender ID 45 15
01,14,20,27,28,
ISA07 Interchange ID Qualifier PIC X(2) ID 2--2 R 60 2
29,30,33,ZZ
ISA08 Interchange Receiver ID PIC X(15) AN 15--15 R Interchange Receiver ID 62 15
ISA09 Interchange Date PIC 9(6) DT 6--6 R Interchange Date (Translator Generated) 77 6 Format is YYMMDD with CC (20) appended
ISA10 Interchange Time PIC 9(4) TM 4--4 R Interchange Time (Translator Generated) 83 4
ISA11 Repetition Separator PIC X(1) ID 1--1 R (Translator Generated) 87 1
ISA12 Interchange Control Version Number PIC X(5) ID 5--5 R 00501 88 5
YJJJ00000 where Y is the last digit of the cycle year,
JJJ is the Julian date of the cycle and 00000 is a
PIC 9(9) sequential number that starts with 00001 and
increments by 1.
ISA13 Interchange Control Number N0 9--9 R 93 9
ISA14 Acknowledgement Requested PIC X(1) ID 1--1 R 0 102 1
ISA15 Usage Indicator PIC X(1) ID 1--1 R P,T 103 1
ISA16 Component Element Separator PIC X(1) 1--1 R Translator Generated 104 1

GS Functional Group Header 1 R ----------- GS 1 18 1

GS01 Functional Identifier Code PIC X(2) ID 2--2 R HP 19 2
GS02 Application Sender's Code PIC X(15) AN 2--15 R Application Sender's Code 21 15
GS03 Application Receiver's Code PIC X(15) AN 2--15 R Application Receiver's Code 36 15

NOTE: All COBOL PICs for "R" defined data elements must start at position 1

Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.

Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)

835 TR3 5010A1

X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC ID Min/Max Usa Loop Loop Repeat Values Page # Loop ID Loop Seq Seg ID Seg. Seq. Start Length Record Repeat Comment
GS04 Date PIC 9(8) DT 8--8 R See ISA09 51 8
GS05 Time PIC 9(8) TM 4--8 R See ISA010 59 8
PIC 9(9) Increament by one; beginning at 001
GS06 Group Control Number N0 1--9 R 67 9

GS07 Responsible Agency Code PIC X(2) ID 1--2 R X 76 2

GS08 Version/Release/Industry ID code PIC X(12) AN 1--12 R 005010X221A1 78 12

ST Transaction Set Header 1 R ------------ 1 68 ST 1 18 1

ST01 Transaction Set Identifier Code PIC X(3) ID 3--3 R 835 19 3
ST02 Transaction Set Control Number PIC X(9) AN 4--9 R =SE02 22 9
ST03 Implementation Convention Reference AN 1-35 N/U Added field ST03 RE: At

BPR Financial Information 1 R ----------- 1 69 BPR 1 18 1

BPR01 Transaction Handling Code PIC X(2) ID 1--2 R C, D, H, I ,P, U, X 19 2
05 Total Actual Provider Payment
Amt
- Group PIC X(18)
05 Total Actual Provider Payment
Amt
- Group REDEF REDEFINES
Total Actual Provider Payment Amt
- Group
10 Total Actual Provider Payment
Amt PIC
S9(8)V99
10 Total Actual Provider Payment
Amt Filler PIC X(8)

BPR02 Total Actual Provider Payment Amt R 1--18 R 21 18

BPR03 Credit or Debit Flag Code PIC X(1) ID 1--1 R C 39 1
BPR04 Payment Method Code PIC X(3) ID 3--3 R ACH,CHK,NON 40 3
BPR05 Payment Format Code PIC X(10) ID 1--10 S CCP,CTX 43 10
BPR06 DFI ID # Qualifier PIC X(2) ID 2--2 S 01 53 2
BPR07 Sender DFI Identifier PIC X(12) AN 3--12 S 55 12
BPR08 Acct # Qualifier PIC X(3) ID 1--3 S DA 67 3
BPR09 Sender Bank Acct # PIC X(35) AN 1--35 S 70 35
BPR10 Payer Identifier PIC X(10) AN 10--10 S 105 10
BPR11 Originating Co Supplemental Code PIC X(9) AN 9--9 S =TRN04 115 9 Not used by Part B

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18

1
 835 Flat File - 5010A1
UPDATED 2/27/2018
835 TR3 5010A1

Legend: Changed field highlighted in yellow

Element COBOL PIC ID Min/Max Usa Loop Loop Repeat Values Page # Loop ID Loop Seq Seg ID Seg. Seq. Start Length Record Repeat Comment
BPR12 DFI ID # Qualifier PIC X(2) ID 2--2 S 01 124 2
BPR13 Receiver or Provider Bank ID # PIC X(12) AN 3--12 S 126 12
BPR14 Acct # Qualifier PIC X(3) ID 1--3 S DA,SG 138 3
BPR15 Receiver or Provider Acct # PIC X(35 AN 1--35 S 141 35
05 Check Issue or EFT Effective
Date - Group PIC X(8)
05 Check Issue or EFT Effective
Date - Group REDEF
REDEFINES
Check Issue or EFT Effective Date
Check Issue or EFT Effective Date - Group
10 Check Issue or EFT Effective
Date PIC 9(8)

BPR16 DT 8--8 R 176 8

BPR17- Business Function Code ID 1-3 N/U
-BPR21

TRN Reassociation Trace Number 1 R ----------- 1 77 TRN 1 18 1

TRN01 Trace Type Code PIC X(2) ID 1--2 R 1 19 2
TRN02 Check or EFT Trace # PIC X(50) AN 1--50 R 21 50
TRN03 Payer Identifier PIC X(10) AN 10--10 R 71 10
TRN04 Originating Co Supplemental Code PIC X(50) AN 1--50 S =BPR011 81 50 Change max from 30 to 50 RE: Attahment w/

CUR Foreign Currency Information 1 S ----------- 1 N/A 79 CUR Medicare does not use th

REF Reference Identification 1 S ----------- 1 REF 1 18 1

REF01 Receiver ID Qualifier PIC X(3) ID 2--3 R EV 82 19 3
REF02 Receiver Identifier PIC X(50) AN 1--50 R 22 50
REF03- Description AN 1-80 N/U
-REF04

REF Version Identification 1 S ----------- 1 REF 1 18 1

REF01 Receiver ID Qualifier PIC X(3) ID 2--3 R F2 84 19 3
REF02 Version ID Code PIC X(50) AN 1--50 R 22 50
REF03- Description AN 1-80 N/U

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

-REF04

DTM Production Date 1 S ----------- 1 85 DTM 1 18 1

DTM01 Date Time Qualifier PIC X(3) ID 3--3 R 405 19 3
05 Production Date - Group PIC
X(8)
05 Production Date - Group -
REDEF REDEFINES
Production Date - Group 10
Production Date
PIC 9(8)
DTM02 Production Date DT 8--8 R CCYYMMDD 22 8
DTM03- Time TM 4-8 N/U
-DTM06

N1 Payer Identification 1 R 1000A 1 87 1000A N1 1 18 1

N101 Entity Identifier Code PIC X(3) ID 2--3 R PR 19 3
N102 Payer Name PIC X(60) AN 1--60 R 22 60 All names expanded to 60 per HIGLAS
N103 ID Code Qualifier PIC X(2) ID 1--2 S XV 82 2
N104 Payer Identifier PIC X(80) AN 2--80 S 84 80
N105- Entity Relationship Code ID 2--2 N/U
-NM106

N3 Payer Address 1 R 1000A 89 1000A N3 1 18 1

N301 Payer Address Line PIC X(55) AN 1--55 R 19 55
N302 Payer Address Line PIC X(55) AN 1--55 S 74 55

N4 Payer City, State, Zip 1 R 1000A 90 1000A N4 1 18 1

N401 Payer City Name PIC X(30) AN 2--30 R 19 30
N402 Payer State Code PIC X(2) ID 2--2 R 49 2
N403 Payer Postal Zone or ZIP Code PIC X(15) ID 3--15 R 51 15
N404 Country Code PIC X(3) ID 2--3 S 66 3
N405- Location Qualifier ID 1-2 N/U

2
 835 Flat File - 5010A1
UPDATED 2/27/2018
835 TR3 5010A1

Legend: Changed field highlighted in yellow

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

-N406
N407 Country Subdivision Code PIC X(3) ID 1--3 S 69 3

REF Additional Payer Identification 4 S 1000A 92 1000A REF 1 18 4

REF01 Reference Identification Qualifier PIC X(3) ID 2--3 R 2U 19 3
REF02 Additional Payer ID PIC X(50) AN 1--50 R 22 50
REF03- Description AN 1--80 N/U
-REF04

PER Payer Business Contact Information 1 S 1000A 94 1000A PER 1 18 1

PER01 Contact Function Code PIC X(2) ID 2--2 R CX 19 2
PER02 Payer Contact Name PIC X(60) AN 1-60 S 21 60 All names expanded to 60 per HIGLAS
PER03 Communication # Qualifier PIC X(2) ID 2--2 S EM,FX,TE 81 2
PER04 Payer Contact Communication PIC X(256) AN 1-256 S 83 256
#
Communication Number Qualifier 2 PIC X(2)
PER05 ID 2--2 S EM,EX,FX,TE 339 2
PER06 Payer Contact Communication PIC X(256) AN 1-256 S 341 256
#
Communication Number Qualifier 3 PIC X(2)
PER07 ID 2--2 S EX 597 2
PER08 Payer Contact Communication PIC X(256) AN 1-256 S 599 256
#
PER09 Contact Inquiry Reference AN 1-20 N/U

PER Payer Technical Contact Information 1 R 1000A 97 1000A PER 1 18 1

PER01 Contact Function Code PIC X(2) ID 2--2 R BL 19 2
PER02 Payer Contact Name PIC X(60) AN 1-60 S 21 60 All names expanded to 60 per HIGLAS
PER03 Communication # Qualifier PIC X(2) ID 2--2 S EM, TE, UR 81 2
PER04 Payer Contact Communication PIC X(256) AN 1-256 S 83 256
#
Communication Number Qualifier 2 PIC X(2)
PER05 ID 2--2 S EM, EX, FX, TE, UR 339 2
PER06 Payer Contact Communication PIC X(256) AN 1-256 S 341 256
#
Communication Number Qualifier 3 PIC X(2)
PER07 ID 2--2 S EM, EX, FX, UR 597 2
PER08 Payer Contact Communication PIC X(256) AN 1-256 S 599 256
#

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

PER09 Contact Inquiry Reference AN 1-20 N/U

PER Payer Web Site 1 S 1000A 100 1000A PER 1 18 1

PER01 Contact Function Code PIC X(2) ID 2--2 R IC 19 2
PER02 Name PIC X(60) AN 1-60 N/U 21 60
PER03 Communication # Qualifier PIC X(2) ID 2--2 R UR 81 2
PER04 Payer Contact Communication PIC X(256) AN 1-256 R 83 256
#
Cummunication Number Qualifier
PER05- ID 2--2 N/U
- PER09

N1 Payee Identification 1 R 1000B 1 102 1000B N1 1 18 1

N101 Entity Identifier Code PIC X(3) ID 2--3 R PE 19 3
N102 Payee Name PIC X(60) AN 1--60 R 22 60 All names expanded to 60 per HIGLAS
N103 Identification Code Qualifier PIC X(2) ID 1--2 R XX, FI, XV 82 2
N104 Payee ID Code PIC X(80) AN 2--80 R 84 80
N105- Entity Relationship Code ID 2--2 N/U
-N106

N3 Payee Address 1 S 1000B 104 1000B N3 1 18 1

N301 Payee Address Line PIC X(55) AN 1--55 R 19 55
N302 Payee Address Line PIC X(55) AN 1--55 S 74 55

N4 Payee City,State,Zip 1 S 1000B 105 1000B N4 1 18 1

N401 Payee City Name PIC X(30) AN 2--30 R 19 30

3
 835 Flat File - 5010A1
UPDATED 2/27/2018
835 TR3 5010A1

Legend: Changed field highlighted in yellow

N402 Payee State Code PIC X(2) ID 2--2 S 49 2
N403 Payee Postal Zone or ZIP Code PIC X(15) ID 3-15 S 51 15
N404 Country Code PIC X(3) ID 2--3 S 66 3
N405- Location Qualifier ID 2--2 N/U

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

-N406
N407 Country Subdivision Code PIC X(3) ID 1--3 S 69 3 Payee Subdivision code per HIGLAS request

REF Payee Additional Identification >1 S 1000B 107 1000B REF 1 18 >1
REF01 Reference Identification Qualifier PIC X(3) ID 2--3 R TJ 19 3
REF02 Additional Payee ID # PIC X(50) AN 1--50 R 22 50
REF03- Description AN 1 80 N/U
-REF04

RDM Remittance Delivery Method 1 S 1000B 109 1 18

RDM01 Report Transmission Code PIC X(2) ID 1--2 BM, EM, FT, OL 19 2
RDM02 Name PIC X(60) AN 1--60 21 60
RDM03 Communication Number PIC X(256) AN 1--256 81 256
RDM04 Reference Identifier N/U
-RDM05

LX Header Number 1 S 2000 >1 111 2000 LX 1 18 1

LX01 Assigned # 05 Assigned Number -GROUP N0 1--6 R 0,1, TTYYMM 19 6 FISS uses TTYYMM -
PIC X(6) Facilit Code/ ear/Month MCS ses 1 for

TS3 Provider Summary Information 1 S 2000 1 112 2000 TS3 1 18 1

TS301 Provider Identifier PIC X(50) AN 1--50 R NPI 19 50 Legacy in case of VA pricing
TS302 Facility Code Value PIC X(2) AN 1--2 R 11,99, Type of Bill 69 2 Part B will use either 11 or 99

TS303 Fiscal Period Date 05 Fiscal Period Date - Group PIC DT 8--8 R CCYYMMDD 71 8
(8)

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

TS304 Total Claim Count 05 Total Claim Count - Group PIC R 1--15 R 79 15
X(15)
05 Total Claim Change Amount -
TS305 Total Claim Change Amount R 1--18 R 94 18
Gro p PIC X(18)
TS306 Total Covered Charge Amount N/U
TS307 Total Noncovered Charge Amount N/U
TS 308 Total Denied Charge Amount N/U
TS 309 Total Provider Amount N/U
TS 310 Total Interest Amount N/U
TS 311 Total Contractual Adjustment Amount N/U
TS312 Total Gramm-Rudman Reduction Amount N/U
TS313 Total MSP Payer Amount 05 Total MSP Payer Amount - R 1--18 S 112 18 Only Part A
Gro p PIC X(18)
TS314 Total Blood Deductible Amount R 1--18 N/U
TS315 Total Non-Lab Charge Amount 05 Total Non-Lab Charge Amount - R 1--18 S 130 18 Only Part A
G PIC X(18)
TS316 Total Coinsurance Amount N/U

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

TS317 Total HCPCS Reported Charge Amount 05 Total HCPCS Reported R 1--18 S 148 18 Only Part A
Charge
05 TotalAmo nt Gro
HCPCS p Amount
Payable
TS318 Total HCPCS Payable Amount R 1--18 S 166 18 Only Part A
TS319 Total Deductible Amount G PIC X(18) R 1--18 N/U

TS320 Total Professional Component Amount 05 Total Professional Component R 1--18 S 184 18 Only Part A
Amo nt Gro p PIC X(18)

4
 835 Flat File - 5010A1
UPDATED 2/27/2018
835 TR3 5010A1

Legend: Changed field highlighted in yellow

TS321 Total MSP Patient Liability Met Amount 05 Total MSP Patient Liability Met R 1--18 S 202 18 Only Part A
A t Patient
05 Total G PIC
Reimbursement
TS322 Total Patient Reimbursement Amount R 1--18 S 220 18 Only Part A
Amo nt Gro p PIC

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

TS323 Total PIP Claim Count 05 Total PIP Claim Count - Group R 1--15 S 238 15 Only Part A
PIC X(15)PIP Adjustment Amount -
05 Total
TS324 Total PIP Adjustment Amount R 1--18 S 253 18 Only Part A
G PIC

TS2 Provider Supplemental Summary Info 1 S 2000 117 2000 TS2 1 18 1 N/U for Part B

TS201 Total DRG Amount 05 Total DRG Amount - Group R 1--18 S 19 18

PIC X(18)Federal Specific Amount -
05 Total
TS202 Total Federal Specific Amount R 1--18 S 37 18
Gro p Hospital Specifc
05 Total PIC X(18)
Amount -
TS203 Total Hospital Specifc Amount R 1--18 S 55 18
G PIC X(18)

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

TS204 Total Disproportionate Amount 05 Total Disproportionate Amount - R 1--18 S 73 18

Gro p Capital Amount
05 Total PIC-X(18)
Group
TS205 Total Capital Amount R 1--18 S 91 18
PIC X(18)Indirect Medical
05 Total
TS206 Total Indirect Medical Education Amount R 1--18 S 109 18
Ed Total
05 ti Outlier
A t GCount -
Day
TS207 Total Outlier Day Count R 1--15 S 127 15
G PIC
05 Total X(15)
Day Outlier Amount -
TS 208 Total Day Outlier Amount R 1--18 S 142 18
Gro p PIC
05 Total X(18)
Cost Outlier Amount -
TS 209 Total Cost Outlier Amount R 1--18 S 160 18
G PIC X(18)

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

TS 210 Average DRG Length of Stay 05 Average DRG Length of Stay - R 1--15 S 178 15
GroTotal
05 p Discharge CountPIC
- Group
TS 211 Total Discharge Count R 1--15 S 193 15
PIC X(15)Cost Report Day Count -
05 Total
TS212 Total Cost Report Day Count R 1--15 S 208 15
G PIC-
05 Total Covered Day Count
TS213 Total Covered Day Count R 1--15 S 223 15
Gro p PIC
05 Total X(15)
Noncovered Day Count-
TS214 Total Noncovered Day Count R 1--15 S 238 15
GroTotal
05 p MSP Pass-Through PIC
TS215 Total MSP Pass-Through Amount R 1--18 S 253 18
A t G PIC

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

TS216 Average DRG Weight 05 Average DRG Weight - Group R 1--15 S 271 15
PICTotal
05 X(15)PPS Capital FSP DRG
TS217 Total PPS Capital FSP DRG Amount R 1--18 S 286 18
Amo nt PSP
05 Total Gro Capital
p PIC
HSP DRG
TS218 Total PSP Capital HSP DRG Amount R 1--18 S 304 18
A t PPS
05 Total G DSH DRG AmountPIC -
TS219 Total PPS DSH DRG Amount R 1--18 S 322 18
G PIC

CLP Claim Level Data 1 R 2100 >1 123 2100 CLP 1 18 1

CLP01 Patient Control # PIC X(38) AN 1--38 R 19 38
CLP02 Claim Status Code PIC X(2) ID 1--2 1,2,3,4, 19, 20, 21, 22, 23 57 2
R

CLP03 Total Claim Charge Amount 05 Total Claim Charge Amount - R 1--18 R 59 18
G PIC

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)

5
 835 Flat File - 5010A1
UPDATED 2/27/2018
835 TR3 5010A1

Legend: Changed field highlighted in yellow

835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

CLP04 Claim Payment Amount 05 Claim Payment Amount - R 1--18 R 77 18

G PIC X(18)
05 Patient Responsibility Amount -
CLP05 Patient Responsibility Amount R 1--18 S 95 18
G PIC X(2)PIC X(18)
CLP06 Claim Filling Indicator Code ID 1--2 R MA/MB 113 2
CLP07 Payer Claim Control # PIC X(50) AN 1--50 S 115 50
CLP08 Facility Code Value PIC X(2) AN 1--2 S 165 2
CLP09 Claim Frequency Code (3rd position of TOB) PIC X(1) ID 1--1 S 167 1 Required when the information was
CLP10 Patient Status Code ID 1-2 N/U
CLP11 DRG Code PIC X(4) ID 1--4 S 168 4 Part A only

CLP12 DRG Weight 05 DRG Weight - Group PIC R 1--15 S 172 15 Part A only
X(15)
05 Discharge Fraction - Group
CLP13 Discharge Fraction R 1--10 S 187 10
Yes/No Condition or Response Code PIC X(10)
CLP14 ID 1--1 N/U

CAS Claim Adjustment 99 S 2100 129 2100 CAS 1 18 99

CAS01 Claim Adjustment Group Code PIC X(2) ID 1--2 R CO, OA, PR 19 2 Group code CR has been deleted
CAS02 Adjustment Reason Code PIC X(5) ID 1--5 R 21 5

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

CAS03 Adjustment Amount 05 Adjustment Amount - Group R 1--18 R 26 18

PICAdjustment
05 X(18) Quantity - Group
CAS04 Adjustment Quantity R 1--15 S 44 15
PIC X(15) PIC X(5)
CAS05 Adjustment Reason Code ID 1--5 S 59 5

CAS06 Adjustment Amount 05 Adjustment Amount - Group R 1--18 S 64 18

PIC X(18)
05 Adjustment Quantity - Group
CAS07 Adjustment Quantity R 1--15 S 82 15
PIC X(15) PIC X(5)
CAS08 Adjustment Reason Code ID 1--5 S 97 5

CAS09 Adjustment Amount 05 Adjustment Amount - Group R 1--18 S 102 18

PICAdjustment
05 X(18) Quantity - Group
CAS10 Adjustment Quantity R 1--15 S 120 15
PIC X(15)

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

CAS11 Adjustment Reason Code PIC X(5) ID 1--5 S 135 5

CAS12 Adjustment Amount 05 Adjustment Amount - Group R 1--18 S 140 18

PIC X(18)
05 Adjustment Quantity - Group
CAS13 Adjustment Quantity R 1--15 S 158 15
PIC X(15) PIC X(5)
CAS14 Adjustment Reason Code ID 1--5 S 173 5

CAS15 Adjustment Amount 05 Adjustment Amount - Group R 1--18 S 178 18

PICAdjustment
05 X(18) Quantity - Group
CAS16 Adjustment Quantity R 1--15 S 196 15
PIC X(15) PIC X(5)
CAS17 Adjustment Reason Code ID 1--5 S 211 5

CAS18 Adjustment Amount 05 Adjustment Amount - Group R 1--18 S 216 18

PIC X(18)

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

CAS19 Adjustment Quantity 05 Adjustment Quantity - Group R 1--15 S 234 15

PIC X(15)

NM1 Patient Name 1 R 2100 137 2100 NM1 1 18 1

NM101 Entity Identifier Code PIC X(3) ID 2--3 R QC 19 3
NM102 Entity Type Qualifier PIC X(1) ID 1--1 R 1 22 1
NM103 Patient Last Name PIC X(60) AN 1--60 S 23 60 All names expanded to 60 per HIGLAS
NM104 Patient First Name PIC X(35) AN 1--35 S 83 35 All last names expanded to 35 per

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NM105 Patient Middle Name PIC X(2) AN 1--25 S 118 25
NM106 Name Prefix AN 1-10 N/U
NM107 Patient Name Suffix PIC X(10) AN 1--10 S NU 143 10
NM108 ID Code Qualifier PIC X(2) ID 1--2 S MI 153 2
NM109 Patient Identifier PIC X(80) AN 2--80 S HIC #, MBI 155 80
NM110- Entity Relationship Code ID 2--2 N/U
-NM112

NM1 Insured's Name 1 S 2100 N/A 140 2100 Not used by Medicare

NM1 Corrected Patient/Insured Name 1 S 2100 143 2100 NM1 1 18 1

NM101 Entity Identifier Code PIC X(3) ID 2--3 R 74 19 3
NM102 Entity Type Qualifier PIC X(1) ID 1--1 R 1 22 1
NM103 Corrected Patient/Ins Last Name PIC X(60) AN 1--60 S 23 60 All names expanded to 60 per HIGLAS
NM104 Corrected Patient/Ins First Name PIC X(35) AN 1--35 S 83 35 All last names expanded to 35 per
NM105 Corrected Patient/Ins Middle Name PIC X(25) AN 1--25 S 118 25
NM106 Name Prefix AN 1-10 N/U
NM107 Corrected Patient Name Suffix PIC X(10) AN 1--10 S 143 10

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

NM108 Identification Code Qualifier PIC X(25) ID 1--2 S C 153 2

Corrected Ins Identification Indicator PIC X(80) Please see Attachment 3 w CR 9700 to
NM109 AN 2--80 S 155 80 determine when to provide the MBI in this
field.

NM110- Entity Relationship Code ID 2--2 N/U

-NM112

NM1 Service Provider Name 1 S 2100 146 2100 NM1 1 18 1

NM101 Entity Identifier Code PIC X(3) ID 2--3 R 82 19 3
NM102 Entity Type Qualifier PIC X(1) ID 1--1 R 1, 2 22 1
NM103 Rendering Provider Last/Org Name PIC X(60) AN 1-60 S 23 60 All names expanded to 60 per HIGLAS
NM104 Rendering Provider First Name PIC X(35) AN 1-35 S 83 35 All last names expanded to 35 per
NM105 Rendering Provider Middle Name PIC X(25) AN 1--25 S 118 25 Required when NM102=1, and NM103
NM106 Name Prefix AN 1-10 N/U
NM107 Rendering Provider Name Suffix PIC X(10) AN 1--10 S 143 10
NM108 ID Code Qualifier PIC X(2) ID 1--2 R XX 153 2
NM109 Rendering Provider Identifier PIC X(80) AN 2--80 R NPI 155 80
NM110- Entity Relationship Code ID 2--2 N/U
-NM112

NM1 Crossover Carrier Name 1 S 2100 150 2100 NM1 1 18 1

NM101 Entity Identifier Code PIC X(3) ID 2--3 R TT 19 3
NM102 Entity Type Qualifier PIC X(1) ID 1--1 R 2 22 1
NM103 COB Carrier Name PIC X(60) AN 1-60 R 23 60 All names expanded to 60 per HIGLAS
NM104 First name AN 1-35 N/U
NM105 Middle name AN 1-25 N/U
NM106 Name Prefix AN 1-10 N/U
NM107 Name suffix AN 1-10 N/U
NM108 ID Code Qualifier PIC X(2) ID 1--2 R PI,XV 83 2
NM109 COB Carrier Identifier PIC X(80) AN 2--80 R 85 80
NM110- Entity Relathionship Code ID 2--2 N/U

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

-NM112

NM1 Corrected Priority Payer Name 1 S 2100 153 2100 NM1 1 18 1

NM101 Entity Identifier Code PIC X(3) ID 2--3 R PR 19 3
NM102 Entity Type Qualifier PIC X(1) ID 1--1 R 2 22 1

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NM103 Corrected Priority Payer Name PIC X(60) AN 1--60 R 23 60 All names expanded to 60 per HIGLAS
NM104 First name AN 1-35 N/U
NM105 middle name AN 1-25 N/U
NM106 Name Prefix AN 1-10 N/U
NM107 Name suffix AN 1-10 N/U
NM108 ID Code Qualifier PIC X(2) ID 1--2 R PI,XV 83 2
NM109 Corrected Priority Payer ID PIC X(80) AN 2--80 R 85 80
NM110- Entity Relationship Code ID 2-2 N/U
-NM112

NM1 Other Subscriber Name N/A 156 Not used by Medicare

MIA Inpatient Adjudication Information 1 S 2100 159 2100 MIA 1 18 1 either MIA or MOA but not both

MIA01 Covered Days or Visits Count 05 Covered Days or Visits Count - R 1--15 R 19 15
Gro p Operating Outlier
05 PPS PICAmount
X(15) -
Group PIC X(18)
05 PPS Operating Outlier Amount
REDEF REDEFINES
PPS Operating Outlier Amount -
Group
10 PPS Operating Outlier Amount
PIC
S9(8)V99
10 PPS Operating Outlier

MIA02 PPS Operating Outlier Amount R 1--18 S 34 18

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

05 Lifetime Psychiatric Days

Count - Group PIC
X(15)
05 Lifetime Psychiatric Days
Count REDEF REDEFINES
Lifetime Psychiatric Days Count -
Group
10 Lifetime Psychiatric Days
Count PIC
S9(3)
10 Lifetime Psychiatric Days
Count Filler PIC
X(12)

MIA03 Lifetime Psychiatric Days Count R 1--15 S 52 15

05 CLAIM DRG AMOUNT -
Group PIC X(18)
05 CLAIM DRG AMOUNT
REDEF REDEFINES
CLAIM DRG AMOUNT -Group
10 CLAIM DRG AMOUNT PIC
S9(8)V99
10 CLAIM DRG AMOUNT Filler
PIC X(8)

MIA04 CLAIM DRG AMOUNT R 1--18 S 67 18

MIA05 CLAIM PAYMENT REMARK CD PIC X(50) AN 1--50 S 85 50

MIA06 CLAIM DSH AMOUNT 05 CLAIM DSH AMOUNT - R 1--18 S 135 18

Gro p PIC X(18)
05 CLAIM MSP PASS THRU
MIA07 CLAIM MSP PASS THRU AMT R 1--18 S 153 18
AMT Gro PPS
05 CLAIM p CAPITAL PIC
AMOUNT - Group
PIC X(18)
05 CLAIM PPS CAPITAL
AMOUNT REDEF REDEFINES
CLAIM PPS CAPITAL AMOUNT -
Group
10 CLAIM PPS CAPITAL
AMOUNT PIC
S9(8)V99
MIA08 CLAIM PPS CAPITAL AMOUNT R 1--18 S 171 18
10 CLAIM PPS CAPITAL

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18

8
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Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

MIA09 PPS CAPITAL FSP DRG AMT 05 PPS CAPITAL FSP DRG R 1--18 S 189 18
AMT Gro
05 PPS p
CAPITAL HSP DRG
MIA10 PPS CAPITAL HSP DRG AMT R 1--18 S 207 18
AMT Gro
05 PPS p
CAPITAL DSH DRG
MIA11 PPS CAPITAL DSH DRG AMT R 1--18 S 225 18
AMTOLD
05 G CAPITAL AMOUNT -PIC
MIA12 OLD CAPITAL AMOUNT R 1--18 S 243 18
G
05 PPSPIC X(18) IME AMOUNT -
CAPITAL
MIA13 PPS CAPITAL IME AMOUNT R 1--18 S 261 18
Gro p PIC

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

MIA14 PPS OPER HSP SPEC DRG AMT S9(8)V99 05 PPS OPER HSP SPEC DRG R 1--18 S 279 18
AMTCOST
05 G REPORT DAY COUNT
PIC
MIA15 COST REPORT DAY COUNT R 1--15 S 297 15
Gro
05 p OPER FSP SPEC
PPS PICDRG
X(15)
MIA16 PPS OPER FSP SPEC DRG AMT R 1--18 S 312 18
AMT Gro PPS
05 CLAIM p OUTLIER PIC
MIA17 CLAIM PPS OUTLIER AMOUNT R 1--18 S 330 18
AMOUNT G
05 CLAIM INDIRECT TEACHING
- Group PIC X(18)
05 CLAIM INDIRECT TEACHING
REDEF REDEFINES
CLAIM INDIRECT TEACHING -
Group
10 CLAIM INDIRECT TEACHING
PIC
S9(8)V99
10 CLAIM INDIRECT TEACHING
Filler PIC

MIA18 CLAIM INDIRECT TEACHING R 1--18 S 348 18

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

05 NON PAY PROF COMP AMT -

Group PIC X(18)
05 NON PAY PROF COMP AMT
REDEF REDEFINES
NON PAY PROF COMP AMT -
Group
10 NON PAY PROF COMP AMT
PIC S9(8)V99
10 NON PAY PROF COMP AMT
Filler PIC X(8)

MIA19 NON PAY PROF COMP AMT R 1--18 S 366 18

MIA20 CLAIM PAYMENT REMARK CD X(5) PIC X(50) AN 1--50 S 384 50
MIA21 CLAIM PAYMENT REMARK CD X(5) PIC X(50) AN 1--50 S 434 50
MIA22 CLAIM PAYMENT REMARK CD X(5) PIC X(50) AN 1--50 S 484 50
MIA23 CLAIM PAYMENT REMARK CD X(5) PIC X(50) AN 1--50 S 534 50
05 PPS CAPITAL EXCEPTION
AMT
- Group PIC X(18)
05 PPS CAPITAL EXCEPTION
AMT REDEF REDEFINES
PPS CAPITAL EXCEPTION
AMT -Group
10 PPS CAPITAL EXCEPTION
AMT PIC S9(8)V99
10 PPS CAPITAL EXCEPTION
AMT Filler PIC X(8)

MIA24 PPS CAPITAL EXCEPTION AMT R 1--18 S 584 18

MOA Outpatient Adjudication Information 1 S 2100 166 2100 MOA 1 18 1 Inpatient Claims. Use either MIA or MOA but

9
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05 Reimbursement Rate - Group
PIC X(10)
05 Reimbursement Rate REDEF
REDEFINES
Reimbursement Rate -Group
10 Reimbursement Rate PIC N/U for Part B
S9(4)V9999
10 Reimbursement Rate Filler PIC
X(2)

MOA01 Reimbursement Rate R 1--10 S 19 10

05 Claim HCPCS Payable
Amount - Group
PIC X(18)
05 Claim HCPCS Payable
Amount REDEF REDEFINES
Claim HCPCS Payable Amount -
Group
10 Claim HCPCS Payable
N/U for Part B
Amount PIC
S9(8)V99
10 Claim HCPCS Payable
Amount Filler PIC
X(8)

MOA02 Claim HCPCS Payable Amount R 1--18 S 29 18

MOA03 CLAIM PAYMENT REMARK CD X(5) PIC X(50) AN 1--50 S 47 50
MOA04 CLAIM PAYMENT REMARK CD X(5) PIC X(50) AN 1--50 S 97 50
MOA05 CLAIM PAYMENT REMARK CD X(5) PIC X(50) AN 1--50 S 147 50

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

MOA06 CLAIM PAYMENT REMARK CD X(5) PIC X(50) AN 1--50 S 197 50

MOA07 CLAIM PAYMENT REMARK CD X(5) PIC X(50) AN 1--50 S 247 50

MOA08 Claim ESRD Payment Amount 05 Claim ESRD Payment Amount - R 1--18 S 297 18
G PIC
05 Nonpayable Professional
Comp Amt - Group PIC
X(18)
05 Nonpayable Professional
Comp Amt REDEF REDEFINES
Nonpayable Professional Comp
Amt -Group
10 Nonpayable Professional
Comp Amt PIC
S9(8)V99
10 Nonpayable Professional
Comp Amt Filler PIC
X(8)
MOA09 Nonpayable Professional Comp Amt R 1--18 S 315 18

REF Other Claim-Related Identification 5 S 2100 169 2100 REF 1 18 N/U by Part B
REF01 Reference ID Qualifier/(Medical Record ID #) PIC X(3) ID 2--3 R EA, 6P, 28, F8 19 3
REF02 Other Claim Related ID/(Medical Record #) PIC X(50) AN 1--50 R 22 50

REF Rendering Provider Identification 10 S 2100 N/A 171 2100 REF N/U by Medicare

DTM Statement From or To Date 2 S 2100 173 2100 DTM 1 18 2

DTM01 Date Time Qualifier PIC X(3) ID 3--3 R 232, 233 19 3

DTM02 Claim Date 05 Claim Date - Group PIC X(8) DT 8--8 R CCYYMMDD 22 8
05 Claim Date Gro p REDEF
DTM03- Time TM 4-8 N/U
-DTM06

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

DTM Coverage Expiration Date 1 S 2100 175 2100 DTM 1 18 1

DTM01 Date/Time Qualifier PIC X(3) ID 3--3 R 036 19 3
05 Coverage Expiration Date -
DTM02 Coverage Expiration Date Group PIC x(8) DT 8--8 R CCYYMMDD 22 8
05 Coverage Expiration Date

10
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DTM03- Time TM 4-8 N/U
-DTM06

DTM Claim Received Date 1 S 2100 177 2100 DTM 1 18 1

DTM01 Date/Time Qualifier PIC X(3) ID 3--3 R 050 19 3

DTM02 Claim Received Date 05 Claim Received Date - Group DT 8--8 R CCYYMMDD 22 8
PIC X(8)
DTM03- Time TM 4-8 N/U
-DTM06

PER Claim Contact Information 2 S 2100 179 2100 PER 1 18 2

PER01 Contact Function Code PIC X(2) ID 2--2 R CX 19 2
PER02 Claim Contact Name PIC X(60) AN 1--60 S 21 60
PER03 Communication # Qualifier PIC X(2) ID 2--2 R EM,FX,TE 81 2
PER04 Claim Contact Communication PIC X(256) AN 1--256 R 83 256
# PIC X(2)
PER05 Communication # Qualifier ID 2--2 S EM,EX,FX,TE 339 2
PER06 Claim Contact Communication PIC X(256) AN 1--256 S 341 256
# PIC X(2)
PER07 Communication # Qualifier ID 2--2 S EX 597 2
PER08 Communication # Extension PIC X(256) AN 1--256 S 599 256
PER09 Contact Inquiry Reference AN 1-20 N/U

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

AMT Claim Supplemental Information 13 S 2100 182 2100 AMT 1 18 13

AMT01 Amount Qualifier Code PIC X(3) ID 1--3 R AU, DY, F5, I, NL, ZK, ZL, ZM, ZN, ZO 19 3
05 Claim Supplemental
Information Amt - Group
PIC X(18)
05 Claim Supplemental
Information Amt REDEF
REDEFINES
Claim Supplemental Information
Amt -Group
10 Claim Supplemental
Information Amt PIC
S9(8)V99
10 Claim Supplemental
Information Amt Filler
PIC X(8)

AMT02 Claim Supplemental Information Amt R 1--18 R 22 18

AMT03 Credit/Debit Flag Code ID 1-1 N/U

QTY Claim Supplemental Infor Quantity 14 S 2100 184 2100 QTY 1 18 14

QTY01 Quantity Qualifier PIC X(2) ID 2--2 R CA, CD, LA, OU ZK, ZL, ZM, ZN, ZO 19 2

QTY02 Claim Supplemental Information Quantity 05 Claim Supplemental R 1--15 R 21 15

Information Q antit Gro p
QTY03- Composite Unit of Measure AN 1-30 N/U N/U
-QTY04

SVC Service Payment Information 1 S 2110 999 186 2110 SVC 1 18 1

SVC01 Composite Medical Procedure Identifier R
-01-1 Product or Service ID Qualifier PIC X(2) ID 2--2 R HC, HP, N4, NU 19 2
-01-2 Adjudicated Procedure Code PIC X(48) AN 1--48 R 21 48
-01-3 Procedure Modifier PIC X(2) AN 2--2 S 69 2
-01-4 Procedure Modifier PIC X(2) AN 2--2 S 71 2
-01-5 Procedure Modifier PIC X(2) AN 2--2 S 73 2

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

-01-6 Procedure Modifier PIC X(2) AN 2--2 S 75 2

-01-7 Procedure Code Description AN 1--80 N/U
-01-8 Product/Service ID AN 1--48 N/U
SVC02 Line Item Charge Amount 05 Line Item Charge Amount - R 1--18 R 77 18
Gro p PIC
05 Line X(18)
Item Provider Payment -
SVC03 Line Item Provider Payment R 1--18 R 95 18
Gro p PIC X(48) PIC
SVC04 NUBC Revenue Code AN 1--48 S 113 48

11
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SVC05 Units of Service Paid Count 05 Units of Service Paid Count - R 1--15 S 161 15
Composite Medical Procedure Identifier G PIC
SVC06 S
-06-1 Product or Service ID Qualifier PIC X(2) ID 2--2 R HC, HP, N4, NU 176 2
-06-2 Procedure Code PIC X(48) AN 1--48 R 178 48
-06-3 Procedure Modifier PIC X(2) AN 2--2 S 226 2
-06-4 Procedure Modifier PIC X(2) AN 2--2 S 228 2
-06-5 Procedure Modifier PIC X(2) AN 2--2 S 230 2
-06-6 Procedure Modifier PIC X(2) AN 2--2 S 232 2
-06-7 Procedure Code Description PIC X(80) AN 1--80 S 234 80 Mediare will populate if received on the claim
-06-8 Product/Service ID AN 1--48 N/U

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

SVC07 Original Units of Service Count 05 Original Units of Service Count R 1--15 S 314 15
Gro p PIC X(15)

DTM Service Date 2 S 2110 194 2110 DTM 1 18 2

DTM01 Date Time Qualifier PIC X(3) ID 3--3 R 150, 151, 472 19 3

DTM02 Service Date 05 Service Date - Group PIC X(8) DT 8--8 R CCYYMMDD 22 8
05 S i D t G REDEF
DTM03- Time TM 4--8 N/U
-DTM06

CAS Service Adjustment 99 S 2110 196 2110 CAS 1 18 99

CAS01 Claim Adjustment Group Code PIC X(2) ID 1--2 R CO,OA,PR 19 2 Group Code CR has been deleted
CAS02 Adjustment Reason Code PIC X(5) ID 1--5 R 21 5

CAS03 Adjustment Amount 05 Adjustment Amount - Group R 1--18 R 26 18

PIC X(18)
05 Adjustment Quantity - Group
CAS04 Adjustment Quantity R 1--15 S 44 15
PIC X(15)

CAS05 Adjustment Reason Code PIC X(5) ID 1--5 S 59 5

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

CAS06 Adjustment Amount 05 Adjustment Amount - Group R 1--18 S 64 18

PICAdjustment
05 X(18) Quantity - Group
CAS07 Adjustment Quantity R 1--15 S 82 15
PIC X(15) PIC X(5)
CAS08 Adjustment Reason Code ID 1--5 S 97 5

CAS09 Adjustment Amount 05 Adjustment Amount - Group R 1--18 S 102 18

PICAdjustment
05 X(18) Quantity - Group
CAS10 Adjustment Quantity R 1--15 S 120 15
PIC X(15) PIC X(5)
CAS11 Adjustment Reason Code ID 1--5 S 135 5

CAS12 Adjustment Amount 05 Adjustment Amount - Group R 1--18 S 140 18

PIC X(18)
05 Adjustment Quantity - Group
CAS13 Adjustment Quantity R 1--15 S 158 15
PIC X(15) PIC X(5)
CAS14 Adjustment Reason Code ID 1--5 S 173 5

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

CAS15 Adjustment Amount 05 Adjustment Amount - Group R 1--18 S 178 18

PIC X(18)
05 Adjustment Quantity - Group
CAS16 Adjustment Quantity R 1--15 S 196 15
PIC X(15) PIC X(5)
CAS17 Adjustment Reason Code ID 1--5 S 211 5

CAS18 Adjustment Amount 05 Adjustment Amount - Group R 1--18 S 216 18

PIC X(18)
05 Adjustment Quantity - Group
CAS19 Adjustment Quantity R 1--15 S 234 15
PIC X(15)

REF Service Identification 8 S 2110 204 2110 REF 1 18 8

REF01 Reference ID Qualifier PIC X(3) ID 2--3 R LU, 1S, APC, RB 19 3 LU - required if the specific site of service
REF02 Reference Identification PIC X(50) AN 1--50 R 22 50
REF03- Description AN 1--80 N/U

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 835 Flat File - 5010A1
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835 TR3 5010A1

Legend: Changed field highlighted in yellow

-REF04

REF Line Item Control Number 1 S 2110 206 2110 REF 1 18 1

REF01 Reference ID Qualifier PIC X(3) ID 2--3 R 6R 19 3
REF02 Line Item Control Number PIC X(50) AN 1--50 R 22 50
REF03- Description AN 1--80 N/U

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

-REF04

REF Rendering Provider Information 10 S 2110 207 2110 REF 1 18 10

REF01 Reference ID Qualifier PIC X(3) ID 2--3 R HPI, SY, TJ, 1C, 1G 19 3
REF02 Rendering Provider ID PIC X(50) AN 1--50 R 22 50
REF03- Description AN 1--80 N/U
-REF04

REF Health Care Policy Identification 5 S 2110 209 2110 REF 1 18 5

REF01 Reference ID Qualifier PIC X(3) ID 2--3 R 0K 19 3
REF02 Reference Identification PIC X(50) AN 1--50 R 22 50 NCD/LCD code
REF03- Description AN 1--80 N/U
-REF04

AMT Service Supplemental Amount 9 S 2110 211 2110 AMT 1 18 12

AMT01 Amount Qualifier Code PIC X(3) ID 1--3 R B6, KH, ZK, ZL, ZM, ZN, ZO 19 3

AMT02 Service Supplemental Amount 05 Service Supplemental Amount - R 1--18 R 22 18

Gro p PIC X(18)
AMT03 Credit/Debit Flag Code ID 1--1 N/U

QTY Service Supplemental Quantity 6 S 2110 N/A 213 2110 QTY Not used by Medicare

LQ Health Care Remarks Codes 99 S 2110 215 2110 LQ 1 18 99

LQ01 Code List Qualifier Code PIC X(3) ID 1--3 R HE 19 3
LQ02 Remark Code X(5) PIC X(30) AN 1--30 R 22 30

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

PLB Provider Level Adjustment >1 S ------- 1 217 PLB 1 18 1

PLB-01 Provider Identifier PIC X(50) AN 1--50 R NPI 19 50 Legacy in case of VA pricing
05 Fiscal Period Date - Group PIC
PLB02 Fiscal Period Date X(8) DT 8--8 R CCYYMMDD 69 8
PLB03 Adjustment Identifier R
50, 51, 72, AP, B2, B3,
PIC X(2) BD, BN, C5, CS, CV, Instruction to use TL - CR from OFM
-03-1 Adjustment Reason Code ID 2--2 R 77 2
DM E3 FB GO HM
-03-2 Provider Adjustment Identifier PIC X(50) AN 1--50 S 79 50
05 Provider Adjustment Amount -
Group PIC X(18)
05 Provider Adjustment Amount
REDEF REDEFINES
Provider Adjustment Amount -
Group
10 Provider Adjustment Amount
PIC S9(8)V99
10 Provider Adjustment Amount
Filler PIC X(8)

PLB04 Provider Adjustment Amount R 1--18 R 129 18

PLB05 Adjustment Identifier S
PIC X(2) 50, 51, 72, AP, B2, B3, Instruction to use TL - CR from OFM
-05-1 Adjustment Reason Code ID 2--2 R BD, BN, C5, CS, CV, 147 2
-05-2 Provider Adjustment Identifier PIC X(50) AN 1--50 149 50
S

13
 835 Flat File - 5010A1
UPDATED 2/27/2018
835 TR3 5010A1

Legend: Changed field highlighted in yellow

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

PLB06 Provider Adjustment Amount 05 Provider Adjustment Amount - R 1--18 S 199 18

G PIC X(18)
PLB07 Adjustment Identifier S
50, 51, 72, AP, B2, B3,
BD, BN, C5, CS, CV,
DM, E3, FB, GO, HM,
PIC X(2) IP, IS, IR, J1, L3, L6, Instruction to use TL - CR from OFM
LE, LS, OA, OB, PI, PL, RA, RE, SL, TL,  WO, WU

-07-1 Adjustment Reason Code ID 2--2 R 217 2

-07-2 Provider Adjustment Identifier PIC X(50) AN 1--50 S 219 50

PLB08 Provider Adjustment Amount 05 Provider Adjustment Amount - R 1--18 S 269 18

Gro p PIC X(18)
PLB09 Adjustment Identifier S
50, 51, 72, AP, B2, B3, Instruction to use TL - CR from OFM
BD, BN, C5, CS, CV,
DM, E3, FB, GO, HM,
PIC X(2) IP, IS, IR, J1, L3, L6,
LE, LS, OA, OB, PI, PL, RA, RE, SL, TL,  WO, WU

-09-1 Adjustment Reason Code ID 2--2 R 287 2

-09-2 Provider Adjustment Identifier PIC X(50) AN 1--50 S 289 50

PLB10 Provider Adjustment Amount 05 Provider Adjustment Amount - R 1--18 S 339 18

Gro p PIC X(18)
PLB11 Adjustment Identifier S

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

50, 51, 72, AP, B2, B3, Instruction to use TL - CR from OFM
BD, BN, C5, CS, CV,
DM, E3, FB, GO, HM,
PIC X(2) IP, IS, IR, J1, L3, L6,
LE, LS, OA, OB, PI, PL, RA, RE, SL, TL,  WO, WU
-11-1 Adjustment Reason Code ID 2--2 R 357 2
-11-2 Provider Adjustment Identifier PIC X(50) AN 1--50 S 359 50

PLB12 Provider Adjustment Amount 05 Provider Adjustment Amount - R 1--18 S 409 18

G PIC X(18)
PLB13 Adjustment Identifier S
50, 51, 72, AP, B2, B3, Instruction to use TL - CR from OFM
BD, BN, C5, CS, CV,
DM, E3, FB, GO, HM,
PIC X(2)
IP, IS, IR, J1, L3, L6,
LE, LS, OA, OB, PI, PL, RA, RE, SL, TL,  WO, WU
-13-1 Adjustment Reason Code ID 2--2 R 427 2
-13-2 Provider Adjustment Identifier PIC X(50) AN 1--50 S 429 50

PLB14 Provider Adjustment Amount 05 Provider Adjustment Amount - R 1--18 S 479 18

Gro p PIC X(18)

SE Transaction Set Trailer 1 R ---- 1 228 SE 1 18 1

SE01 Transition Segment Count PIC 9(10) N0 1--10 R 19 10
SE02 Transition Set Control # PIC X(9) AN 4--9 R =ST02 29 9

GE Functional Group Trailer 1 R --- GE 1 18 1

NOTE: All COBOL PICs for "R" defined data elements must start at position 1
Amount Fields: Must be right justified zero filled for the first 10 positions and space filled from 11-18 positions.
Amount Fields: If no data to report, all 18 positions would be space filled (Exception: FISS may zero fill the first 10 and space fill from 11-18 positions)
835 TR3 5010A1
X12 Element Attributes--------------------------------------------------------------------------- X12 Flat File----------- 18
Element COBOL PIC Usa Loop Repeat Loop ID Record Repeat
Identifier ge
ID Min/Max Req Loop Values Page # Loop Seq Seg ID Seg. Seq. Start Length Comment

GE01 # Transaction Sets Included PIC 9(6) N0 1-6 R Total transaction sets (ST-SE pairs) 19 6
GE02 Group Control # PIC 9(9) N0 1-9 R Same Value as in GS06 25 9

IEA Interchange Control Trailer 1 R ---- IEA 1 18 1

IEA01 # Included Functional Groups PIC 9(5) N0 1-5 R Total functional groups (GS-GE pairs) 19 5

14
 835 Flat File - 5010A1
UPDATED 2/27/2018
835 TR3 5010A1

Legend: Changed field highlighted in yellow

IEA02 Interchange Control # PIC 9(9) N0 9-9 R Same value as in ISA13 24 9

15