This section specifies X12N 835 fields for which Florida Medicaid has specific rules and requirements.
835 Health Care Claim Payment and Remittance Advice Page Loop ID Reference Name Code/Value Notes/Comments
69 N/A BPR Financial
Total payment amount for paid and denied claims always contains the correct total payment amount for the week.
Transaction Trace Number 77 N/A TRN02 Reference the payment number when the paid amount is zero.
78 N/A TRN03 Originating Company Identifier (Payer Identifier)
593452939 ‘593452939’ – Florida Medicaid Tax ID
82 N/A REF Receiver
If different than Florida Medicaid Provider ID 85 N/A DTM Production Date
85 N/A DTM01 Date/Time 405 ‘405’ - Production
835 Health Care Claim Payment and Remittance Advice Page Loop ID Reference Name Code/Value Notes/Comments
Qualifier
Information Suite 100 90 1000A N4 Payer City, State,
91 1000A N403 Postal Code 323093574
102 1000B N1 Payee
Identification 103 1000B N103 Identification
Code Qualifier FI, XX FI – Federal Taxpayer’s Identification Number XX – Health Care Financing Administration National Provider Identifier 103 1000B N104 Identification
Code
‘TJ’ – Federal Taxpayer’s Identification Number Provider Medicaid ID If REF01 =’TJ’ – Tax ID 123 2100 CLP Claim Payment
Information
835 Health Care Claim Payment and Remittance Advice Page Loop ID Reference Name Code/Value Notes/Comments
Secondary (Medicare Crossover Claims)
‘4’ – All Denied (Regular &
Crossover Claims)
‘22’ - Reversal of a previous claim submission
126 2100 CLP06 Claim Filing
Indicator Code MC ‘MC’ - Medicaid 128 2100 CLP11 Diagnosis Related
Group (DRG)
Displays the Adjustment (cutback) Amount.
The X12N 835 contains information regarding the difference between the submitted charge, (Loop 2100, Segment CLP03) and the approved payment amount, (Loop 2100, Segment CLP04).
For example: If a provider bills $750.00 for a procedure that allows a maximum of
$500.00, $250.00 is
reported as a cutback amount.
137 2100 NM1 Patient Name 137 2100 NM101 Entity Identifier
Code QC ‘QC’ - Patient
138 2100 NM103 Name Last or Organization Name
Recipient last name as stored on Florida Medicaid file. If recipient not found on file, the value is the recipient last name submitted on claim.
138 2100 NM104 Name First Recipient first name as stored on Florida Medicaid file. If recipient not found on file, the value is the recipient first name submitted on claim.
835 Health Care Claim Payment and Remittance Advice Page Loop ID Reference Name Code/Value Notes/Comments 139 2100 NM108 Identification
Code Qualifier
‘MR’ – Medicaid Recipient Identification Number 139 2100 NM109 Identification
Code
Florida Recipient 10-digit Medicaid ID
146 2100 NM1 Service Provider Name
147 2100 NM101 Entity Identifier Code
82 ‘82’ – Rendering Provider
148 2100 NM108 Identification
Code Qualifier XX, MC ‘XX’ – National Provider Identification Number
‘MC’ – Provider Medicaid ID 149 2100 NM109 Identification Code If NM108 = ’XX’ – NPI ID
If NM108 = ’MC’ – Medicaid ID
153 2100 NM1 Corrected Priority Payer Name 153 2100 NM101 Entity Identifier
Code
PR ‘PR’ – Payer 154 2100 NM108 Identification Code
Qualifier PI ‘PI’ – Payor Identification 154 2100 NM109 Identification
Code
TPL Carrier Code 159 2100 MIA Inpatient
Adjudication Information 160 2100 MIA01 Quantity (Covered
Days or Visits Count)
Default to ‘0’
Note: Institutional only 161 2100 MIA04 Monetary Amount
(Claim DRG Amount)
Use this monetary amount for the DRG dollar amount.
Note: Institutional only 161 2100 MIA05 Reference
Identification (Remark Code)
HIPAA Remark Code for Inpatient and Institutional Regular and Crossover claims.
Remark Codes can be found on http://www.wpc-edi.com 164 2100 MIA20 Reference
identification
HIPAA Remark Code for Inpatient and Institutional
835 Health Care Claim Payment and Remittance Advice Page Loop ID Reference Name Code/Value Notes/Comments
Remark Codes can be found on http://www.wpc-edi.com 167 2100 MOA04 Reference
Identification (Remark Code)
HIPAA Remark Code for Outpatient/ Professional Crossover claims (2)
169 2100 REF Other Claim Record ID Number
170 2100 REF02 Reference Identification (Other Claim Related Identifier)
Medical Record ID Number as submitted on claim.
SY ‘SY’ – Social Security Number
170 2100 REF02 Reference Identification (Other Claim Related Identifier)
Recipient SSN
169 2100 REF01 Reference Identification Code(Other Claim Related Identifier)
9C ‘9C’ – Adjusted
Repriced Claim Reference
170 2100 REF02 Reference Identification (Other Claim Related Identifier)
Adjusted ICN Related Identifier)
Duplicate ICN
‘233’ – Claim Statement Period End
174 2100 DTM02 Claim Date If DTM=’232’ value contains
Start Date.
835 Health Care Claim Payment and Remittance Advice Page Loop ID Reference Name Code/Value Notes/Comments
If DTM=’233’ value c ontain End Date.
If invalid date received on original claim, value contains default date of 19000101.
175 2100 DTM Coverage
Expiration Date 175 2100 DTM01 Date/Time
Qualifier 036 ‘036’ – Expiration
175 2100 DTM02 Date If DTM=’036’ value
contains Recipient’s last year and month of eligibility.
184 2100 QTY Claim
Note: Institutional only.
186 2110 SVC Service Payment Information 187 2110 SVC01-1 Product/Service ID
Qualifier
AD, HC, N4, NU
‘AD’ – American
Dental Association Codes
‘HC’ – Health Care Financing Administration
‘N4’ (Encounters Only) – National Drug Code (NDC), Universal Product Code (UPC)
‘NU’ – National Uniform Billing Committee (NUBC) UB92
Up to four (4) Procedure Code Modifiers per Detail.
191 2110 SVC06-1 Product/Service ID AD, HC, N4, ‘AD’ – American Dental
835 Health Care Claim Payment and Remittance Advice Page Loop ID Reference Name Code/Value Notes/Comments
‘NU’ – National Uniform Billing Committee (NUBC) UB92
192 2110 SVC06-2 Product/Service ID Qualifier
Reports original code billed on claim.
192 2110 SVC06-3 - SVC06-6
Procedure Modifier
Up to four (4) Procedure Code Modifiers per Detail.
193 2110 SVC07 Quantity (Original Units of Service Count)
Units of Service are reported here if different than the original billed units.
196 2110 CAS Service
Adjustment Reason Codes can be found on http://www.wpc-edi.com
Difference between the line billed charged and line Medicaid paid amount.
204 2110 REF Service
Identification
This segment will only appear for claims that are not in denied status and with an EAPG code present.
204 2110 Ref01 Reference Identification Qualifier
1S ‘1S’ – Enhanced Ambulatory Patient Grouping (EAPG) 204 2110 REF02 Reference
Identification 6R ‘6R’ - Provider Control Number
206 REF02 Reference
Identification
Original Line Item Control Number from 835-claim line 207 2110 REF Rendering
If REF01=’1D’ – Florida Medicaid Provider ID If REF01=’HPI’ - NPI
835 Health Care Claim Payment and Remittance Advice Page Loop ID Reference Name Code/Value Notes/Comments
211 2110 AMT Service
Supplemental Amount
211 2110 AMT01 Amount Qualifier Code
‘ZM’ – Outlier Payment Amount
‘ZN’ – Self-Funded IGT Payment
‘ZO’ – Maximum Policy Adjuster
Present only if EAPG Weight is greater than 0.
‘ZL’ – EAPG Payment Percentage. Present only if EAPG Payment Percentage is greater than 0.
‘ZO’ - Maximum Policy Adjuster. Present only if AMT01 = ZO
Remark Codes if needed to communicate additional information about the denial or adjustment of a claim or service line that cannot be thoroughly explained by a Claim
835 Health Care Claim Payment and Remittance Advice Page Loop ID Reference Name Code/Value Notes/Comments 218 Summary PLB02 Date (Fiscal Period
Date)
Accounts Receivable Financial Cost Settlement Fiscal Year End Date OR Set-up date for A/R transaction.
For a Negative Net Payment Amount this field contains the Remittance Date.
223-227
Summary PLB04, PLB06,
The monetary amount for the adjustment to the preceding adjustment code.
Amount of increase/decrease OR amount received/
recouped OR Negative Net Payment Amount.
Note: As required for HIPAA compliance, only amounts that affect the remittance check amount is reported in the PLB segment.
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11 Appendices
The following sections contain these appendices:
Appendix A – Implementation Checklist;
Appendix B – Business Scenarios;
Appendix C – Transmission Examples;
Appendix D – Frequently Asked Questions; and Appendix E – Change Summary
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