835 Health Care Claim Payment/Advice

Transcription

1 835 Health Care Claim Payment/Advice Functional Group ID=HP Introduction: This document contains the format and establishes the data contents of the Health Care Claim Payment/Advice Transaction Set (835) for use within the context of the Electronic Data Interchange (EDI) environment. The HIPAA 835 is an electronic remittance advice (ERA). ERA is an electronic version of the paper claim payment notice. There are other terms associated with this type of document, such as: explanation of benefits (EOB), explanation of payment (EOP), payment advice, remittance notification, and numerous variations of this. Regardless of the name, we are referring to the documentation that notifies medical providers on the final disposition of healthcare claims that were submitted to CIGNA. ERAs are used only for providers, never to notify an insured, patient, or other nonprovider entity. Following are some basic ground rules for the ERA: 1. An ERA isn't simply a print image of the paper payment advice. It is a flat file, which is intended to be processed by computer applications in the provider's office. It isn't intended to be read by people, as the file is created as an unbroken and (seemingly) unformatted data stream. There is a format to it, but not such that it can easily be read by humans. 2. The Health Insurance Portability and Accountability Act (HIPAA) requires the use of a standardized file format when transmitting ERA data between 2 or more entities. The standard that was adopted is based on the ANSI ASC X version 4010 (835). The CIGNA process will generate a HIPAA compliant file format. General Document Information: This transaction guide contains transaction level notes on the first page; these notes are followed by a series of tables that represent loop and segment usage for the 835 transaction. At the end of the note section, but prior to the tables, a sub-header CIGNA NOTES has been inserted and specific information, concerning CIGNA s use of the information contained in the 835 transaction set is defined. At every segment and element level CIGNA Notes have been included to help guide the user. 1. Following are definitions of the Usage Indicators for the tables representing loop and segment usage, which begin on page 3: M - This implies that this is a Mandatory segment and there is no dependency on other data segments. This data segment must be included in the 835 transaction set. (Note: a data Segment may be mandatory in a loop of data segments, but the loop itself is optional if the beginning segment of the loop is designated as optional.) CIGNA will always provide this segment when the loop is used. Must Use - This is being used for the segments which are situational, per the ANSI ASC X version 4010 standard, but CIGNA has decided to provide them in all the 835 transaction sets. Used - This is being used for the segments that are situational, per the ANSI ASC X version 4010 standard. CIGNA will provide these segments only when they are needed to report situational information. 2. Following are definitions of the Usage Indicators for the Segment levels that begin on page 5: Mandatory - This implies that this is a Mandatory segment and there is no dependency on other data segments. This data segment must be included in the 835 transaction set. (Note: a data Segment may be mandatory in a loop of data segments, but the loop itself is optional if the beginning segment of the loop is designated as optional.) CIGNA will always provide this segment when the loop is used. 835CIGNA (004010X091A1) 1 December 30, 2002

2 Optional - This is being used for the segments which are situational, per the ANSI ASC X version 4010 standard. CIGNA will provide these segments only when they are needed to report situational information. Optional (Must Use) - This is being used for the segments which are situational, per the ANSI ASC X version 4010 standard, but CIGNA has decided to provide them in all the 835 transaction sets. Optional (Not Recommended) - This is being used for the situational segments that are advised not to be sent by the ANSI ASC X version 4010 standard. CIGNA will provide them in some specific situations. 3. Following are definitions of the Usage Indicators for individual Elements that begin on page 5: M - This implies that this is a Mandatory/Required element whenever the segment in which the element is contained is being used. CIGNA will always provide this element when the segment is used. Must Use - This is being used for the elements which are situational, per the ANSI ASC X version 4010 standard, but CIGNA has decided to always provide this element when the segment is used. Used - This is being used for the elements, which are situational/optional, per the ANSI ASC X version 4010 standard. The presence of a value for a simple data element or the presence of value for any of the component data elements of a composite data structure is at the option of CIGNA. Not Used - These are elements shouldn t be used, per the ANSI ASC X version 4010 standard. This also includes elements that CIGNA has determined will never be used in the 835 transaction. CIGNA will never provide these elements. 835CIGNA (004010X091A1) 2 December 30, 2002

3 Notes: CIGNA NOTES 1. This is CIGNA's Companion Guide for Trading Partners, who will receive the 835 files sent by CIGNA. This document will explain for the receiver how CIGNA will send a V , and what information it will carry. This document has been modeled after the ANSI guide for version 4010(X12) of the 835 transaction set with the available options set forth by the HIPAA regulations. This was originally published in May 2000 as X091, and includes the addendum published in October 2002 as X091A1. This document includes only a subset of the entire 835 transaction set. All of the elements that are REQUIRED by HIPAA are also REQUIRED by CIGNA. Segments that are defined as SITUATIONAL by HIPAA but are used by CIGNA are noted as REQUIRED. Some SITUATIONAL and OPTIONAL segments that are included in the HIPAA guide and are not used by CIGNA are noted as NOT USED. There are segments that are SITUATIONAL that CIGNA may or may not use and are therefore included in this document. These segments will appear in the transaction, when appropriate. 2. This version of CIGNA's Companion Guide doesn't provide any details about the usage of ISA, IEA, GS and GE segments. 3. As stated in the addendum published October 2002, the utilization of decimal data elements in Data Element 782 (Monetary Amount) will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). Note the statement in the preceding paragraph that the decimal point and leading sign, if sent, are not part of the character count. 4. CIGNA utilizes up to 10 occurrences of REF (Payee Additional Identification) segment in the 1000B loop 5. CIGNA doesn't utilize Payer Contact Information (PER) segment in the loop 1000A. 6. CIGNA doesn't utilize Corrected Patient/Insured Name (NM1) segment in the loop CIGNA doesn't utilize Crossover Carrier Name (NM1) segment in the loop Heading: Pos. Seg. Req. Loop Notes and No. ID Name Des. Max.Use Repeat Comments M 010 ST Transaction Set Header M 1 M 020 BPR Financial Information M 1 M 040 TRN Reassociation Trace Number M 1 c1 Used 050 CUR Foreign Currency Information O 1 c2 Must Use 060 REF Receiver Identification O 1 Used 060 REF Version Identification O 1 Must Use 070 DTM Production Date O 1 c3 LOOP ID A 1 M 080 N1 Payer Identification M 1 M 100 N3 Payer Address M 1 M 110 N4 Payer City, State, ZIP Code M 1 Used 120 REF Additional Payer Identification O 4 LOOP ID B 1 M 080 N1 Payee Identification M 1 Must Use 100 N3 Payee Address O 1 Must Use 110 N4 Payee City, State, ZIP Code O 1 n1 Used 120 REF Payee Additional Identification O >1 835CIGNA (004010X091A1) 3 December 30, 2002

4 Detail: Pos. Seg. Req. Loop Notes and No. ID Name Des. Max.Use Repeat Comments LOOP ID >1 Used 003 LX Header Number O 1 Used 005 TS3 Provider Summary Information O 1 Used 007 TS2 Provider Supplemental Summary Information O 1 LOOP ID >1 M 010 CLP Claim Payment Information M 1 Used 020 CAS Claim Adjustment O 99 M 030 NM1 Patient Name M 1 n2 Used 030 NM1 Insured Name O 1 n3 Used 030 NM1 Service Provider Name O 1 Used 030 NM1 Corrected Priority Payer Name O 2 Used 033 MIA Inpatient Adjudication Information O 1 Used 035 MOA Outpatient Adjudication Information O 1 Used 040 REF Other Claim Related Identification O 5 Used 040 REF Rendering Provider Identification O 10 Must Use 050 DTM Claim Date O 4 Must Use 060 PER Claim Contact Information O 3 Used 062 AMT Claim Supplemental Information O 14 Used 064 QTY Claim Supplemental Information Quantity O 15 LOOP ID Used 070 SVC Service Payment Information O 1 Used 080 DTM Service Date O 3 Used 090 CAS Service Adjustment O 99 Used 100 REF Service Identification O 7 Used 100 REF Rendering Provider Information O 10 Used 110 AMT Service Supplemental Amount O 12 Used 120 QTY Service Supplemental Quantity O 6 Used 130 LQ Health Care Remark Codes O 99 Summary: Pos. Seg. Req. Loop Notes and No. ID Name Des. Max.Use Repeat Comments Used 010 PLB Provider Adjustment O >1 M 020 SE Transaction Set Trailer M 1 Transaction Set Notes 1. The CAS segment is used to reflect changes to amounts within Table The DTM segment in the SVC loop is to be used to express dates and date ranges specifically related to the service identified in the SVC segment. 3. The CAS segment is used to reflect changes to amounts within Table 2. Transaction Set Comments 1. The TRN segment is used to uniquely identify a claim payment and advice. 2. The CUR segment does not initiate a foreign exchange transaction. 3. The N1 loop allows for name/address information for the payer and payee which would be utilized to address remittance(s) for delivery. 835CIGNA (004010X091A1) 4 December 30, 2002

5 Segment: ST Transaction Set Header Position: 010 Loop: Level: Heading Usage: Mandatory Max Use: 1 Purpose: To indicate the start of a transaction set and to assign a control number Syntax Notes: Semantic Notes: 1 The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set). Comments: Notes: CIGNA will always provide this segment. Example: ST*835*1234~ Data Element Summary Ref. Data Des. Element Name Attributes M ST Transaction Set Identifier Code M ID 3/3 Code uniquely identifying a Transaction Set The only valid value within this transaction set for ST01 is 835. INDUSTRY: Transaction Set Identifier Code 835 Health Care Claim Payment/Advice M ST Transaction Set Control Number M AN 4/9 Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set The Transaction Set Control Numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Start with a number, for example 0001, and increment from there. This number must be unique within a specific group and interchange, but it can be repeated in other groups and interchanges. INDUSTRY: Transaction Set Control Number CIGNA generates a 9-digit ID, which increments by 1 for each ST segment created. The 1st ID generated would be ' '. 835CIGNA (004010X091A1) 5 December 30, 2002

6 Segment: BPR Financial Information Position: 020 Loop: Level: Heading Usage: Mandatory Max Use: 1 Purpose: To indicate the 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 Syntax Notes: 1 If either BPR06 or BPR07 is present, then the other is required. 2 If BPR08 is present, then BPR09 is required. 3 If either BPR12 or BPR13 is present, then the other is required. 4 If BPR14 is present, then BPR15 is required. 5 If either BPR18 or BPR19 is present, then the other is required. 6 If BPR20 is present, then BPR21 is required. Semantic Notes: 1 BPR02 specifies the payment amount. 2 When using this transaction set to initiate a payment, all or some of BPR06 through BPR16 may be required, depending on the conventions of the specific financial channel being used. BPR06 and BPR07 relate to the originating depository financial institution (ODFI). 3 BPR08 is a code identifying the type of bank account or other financial asset. 4 BPR09 is the account of the company originating the payment. This account may be debited or credited depending on the type of payment order. 5 BPR12 and BPR13 relate to the receiving depository financial institution (RDFI). 6 BPR14 is a code identifying the type of bank account or other financial asset. 7 BPR15 is the account number of the receiving company to be debited or credited with the payment order. 8 BPR16 is the date the originating company intends for the transaction to be settled (i.e., Payment Effective Date). 9 BPR17 is a code identifying the business reason for this payment. 10 BPR18, BPR19, BPR20 and BPR21, if used, identify a third bank identification number and account to be used for return items only. 11 BPR20 is a code identifying the type of bank account or other financial asset. Comments: Notes: Use the BPR to address a single payment to a single payee. A payee may represent a single provider, a provider group, or multiple providers in a chain. The BPR contains mandatory information, even when it is not being used to move funds electronically. CIGNA will always provide this segment. Example: BPR*C*150000*C*ACH*CTX*01* *DA*123456* * *01* *DA*98765* ~ Data Element Summary Ref. Data Des. Element Name Attributes M BPR Transaction Handling Code M ID 1/2 Code designating the action to be taken by all parties INDUSTRY: Transaction Handling Code C Payment Accompanies Remittance Advice Use this code to instruct your third party processor to move both funds and remittance detail together through the banking system. D Make Payment Only Use this code to instruct your third party processor to move only funds through the banking system and to ignore any remittance information. H Notification Only 835CIGNA (004010X091A1) 6 December 30, 2002

7 I P U X Use this code to pass information only without any reference to payment. Usually this code is used to pass predetermination of benefits information from a payer to a provider. Remittance Information Only Use this code to indicate to the payee that the remittance detail is moving separately from the payment. Prenotification of Future Transfers This code is used only by the payer and the banking system to initially validate account numbers before beginning an EFT relationship. Contact your VAB for additional information. Split Payment and Remittance Use this code to instruct the third party processor to split the payment and remittance detail, and send each on a separate path. Handling Party's Option to Split Payment and Remittance Use this code to instruct the third party processor to move the payment and remittance detail, either together or separately, based upon end point requests or capabilities. M BPR Monetary Amount M R 1/18 Use BPR02 for the total payment amount for this 835. The total payment amount for this 835 cannot exceed eleven characters, including decimals ( ). Although the value can be zero, the 835 cannot be issued for less than zero dollars. INDUSTRY: Total Actual Provider Payment Amount M BPR Credit/Debit Flag Code M ID 1/1 Code indicating whether amount is a credit or debit INDUSTRY: Credit or Debit Flag Code M BPR Payment Method Code M ID 3/3 Code identifying the method for the movement of payment instructions INDUSTRY: Payment Method Code ACH Automated Clearing House (ACH) Use this code to move money electronically through the ACH, or to notify the provider that an ACH transfer was requested. When this code is used, information in BPR05 through BPR15 must also be included. BOP Financial Institution Option Use this code to indicate that the third party processor will choose the method of payment based upon end point requests or capabilities. CHK Check Use this code to indicate that a check has been issued for payment. FWT Federal Reserve Funds/Wire Transfer - Nonrepetitive Use this code to indicate that the funds were sent through the wire system. NON Non-Payment Data Use this code when the Transaction Handling Code 835CIGNA (004010X091A1) 7 December 30, 2002

8 (BPR01) is H, indicating that this is information only and no dollars are to be moved. Used BPR Payment Format Code O ID 1/10 Code identifying the payment format to be used When BPR04 is ACH, the recommended code values for BPR05 are CCP and CTX. When BPR04 is any other code, this data element should not be used. INDUSTRY: Payment Format Code CCP Cash Concentration/Disbursement plus Addenda (CCD+) (ACH) Use the CCD+ format to move money and up to 80 characters of data, enough to reassociate dollars and data when the dollars are sent through the ACH and the data is sent on a separate path. The addenda should contain a copy of the TRN segment. CTX Corporate Trade Exchange (CTX) (ACH) Use the CTX format to move dollars and data through the ACH. The CTX format can contain up to 9,999 addenda records of 80 characters each. The CTX encapsulates the complete 835 and all envelope segments. Used BPR (DFI) ID Number Qualifier X ID 2/2 Code identifying the type of identification number of Depository Financial Institution (DFI) BPR06 through BPR09 relate to the originating financial institution and the originator's account (payer). This element is required when BPR04 is ACH, BOP or FWT. INDUSTRY: Depository Financial Institution (DFI) Identification Number Qualifier 01 ABA Transit Routing Number Including Check Digits (9 digits) ABA is a unique number identifying every bank in the United States. 04 Canadian Bank Branch and Institution Number Used BPR (DFI) Identification Number X AN 3/12 Depository Financial Institution (DFI) identification number Use this number for the identifying number of the financial institution sending the transaction into the ACH network. This element is required when BPR04 is ACH, BOP or FWT. INDUSTRY: Sender DFI Identifier Used BPR Account Number Qualifier O ID 1/3 Code indicating the type of account Use this code to identify the type of account in BPR09. This element is required when BPR04 is ACH, BOP or FWT. INDUSTRY: Account Number Qualifier DA Demand Deposit Used BPR Account Number X AN 1/35 835CIGNA (004010X091A1) 8 December 30, 2002

9 Account number assigned Use this number for the originator's account number at his or her financial institution. This element is required when BPR04 is ACH, BOP or FWT. INDUSTRY: Sender Bank Account Number Used BPR Originating Company Identifier O AN 10/10 A unique identifier designating the company initiating the funds transfer instructions. The first character is one-digit ANSI identification code designation (ICD) followed by the nine-digit identification number which may be an IRS employer identification number (EIN), data universal numbering system (DUNS), or a user assigned number; the ICD for an EIN is 1, DUNS is 3, user assigned number is 9 BPR10 must be the Federal Tax ID Number, preceeded by a "1." When BPR10 is used, it must be identical to TRN03. This element is required when BPR04 is ACH, BOP or FWT. INDUSTRY: Payer Identifier Used BPR Originating Company Supplemental Code O AN 9/9 A code defined between the originating company and the originating depository financial institution (ODFI) that uniquely identifies the company initiating the transfer instructions Use this code to further identify the payer by division or region. If used, this code must be identical to TRN04. This element is required when BPR10 is used and additional information is necessary for the payee to identify the source of the payment. INDUSTRY: Originating Company Supplemental Code Used BPR (DFI) ID Number Qualifier X ID 2/2 Code identifying the type of identification number of Depository Financial Institution (DFI) BPR12 through BPR15 relate to the receiving financial institution and the receiver's account. This element is required when BPR04 is ACH, BOP or FWT. INDUSTRY: Depository Financial Institution (DFI) Identification Number Qualifier 01 ABA Transit Routing Number Including Check Digits (9 digits) ABA is a unique number identifying every bank in the United States. 04 Canadian Bank Branch and Institution Number Used BPR (DFI) Identification Number X AN 3/12 Depository Financial Institution (DFI) identification number Use this number for the identifying number of the financial institution receiving the transaction from the ACH network. This element is required when BPR04 is ACH, BOP or FWT. 835CIGNA (004010X091A1) 9 December 30, 2002

10 INDUSTRY: Receiver or Provider Bank ID Number Used BPR Account Number Qualifier O ID 1/3 Code indicating the type of account Use this code to identify the type of account in BPR15. This element is required when BPR04 is ACH, BOP or FWT. INDUSTRY: Account Number Qualifier DA Demand Deposit SG Savings Used BPR Account Number X AN 1/35 Account number assigned Use this number for the receiver's account number at the financial institution. This element is required when BPR04 is ACH, BOP or FWT. INDUSTRY: Receiver or Provider Account Number M BPR Date M DT 8/8 Date expressed as CCYYMMDD Use this code for the effective entry date. If BPR04 is ACH, this code is the date that the money moves from the payer and is available to the payee. If BPR04 is CHK, this code is the check issuance date. If BPR04 is FWT, this code is the date that the payer anticipates the money to move. As long as the effective date is a business day, this is the settlement date. If BPR04 is 'NON', enter the date of the 835. INDUSTRY: Check Issue or EFT Effective Date Not Used BPR Business Function Code O ID 1/3 Code identifying the business reason for this payment Not Used BPR (DFI) ID Number Qualifier X ID 2/2 Code identifying the type of identification number of Depository Financial Institution (DFI) Not Used BPR (DFI) Identification Number X AN 3/12 Depository Financial Institution (DFI) identification number Not Used BPR Account Number Qualifier O ID 1/3 Code indicating the type of account Not Used BPR Account Number X AN 1/35 Account number assigned 835CIGNA (004010X091A1) 10 December 30, 2002

11 Segment: TRN Reassociation Trace Number Position: 040 Loop: Level: Heading Usage: Mandatory Max Use: 1 Purpose: To uniquely identify a transaction to an application Syntax Notes: Semantic Notes: 1 TRN02 provides unique identification for the transaction. 2 TRN03 identifies an organization. 3 TRN04 identifies a further subdivision within the organization. Comments: Notes: This segment's purpose is to uniquely identify this transaction set and to aid in reassociating payments and remittances that have been separated. CIGNA will always provide this segment. Example: TRN*1*12345* * ~ Data Element Summary Ref. Data Des. Element Name Attributes M TRN Trace Type Code M ID 1/2 Code identifying which transaction is being referenced INDUSTRY: Trace Type Code 1 Current Transaction Trace Numbers M TRN Reference Identification M AN 1/30 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier This number must be unique within the sender/receiver relationship. The number is assigned by the sender. For example, if a payment is made by check, this number should be the check number. There may be a number of uses for the trace number. If payment and remittance detail are separated, this number is used to reassociate data to dollars. See 2.2.3, Reassociation of Data and Dollars. INDUSTRY: Check or EFT Trace Number M TRN Originating Company Identifier M AN 10/10 A unique identifier designating the company initiating the funds transfer instructions. The first character is one-digit ANSI identification code designation (ICD) followed by the nine-digit identification number which may be an IRS employer identification number (EIN), data universal numbering system (DUNS), or a user assigned number; the ICD for an EIN is 1, DUNS is 3, user assigned number is 9 TRN03 must contain the Federal Tax ID Number, preceded by a "1." When BPR10 is used, it must be identical to TRN03. INDUSTRY: Payer Identifier Used TRN Reference Identification O AN 1/30 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier If both TRN04 and BPR11 are used, they must be identical. 835CIGNA (004010X091A1) 11 December 30, 2002

12 This element is required when information beyond the Originating Company Identifier in TRN03 is necessary for the payee to identify the source of the payment. INDUSTRY: Originating Company Supplemental Code 835CIGNA (004010X091A1) 12 December 30, 2002

13 Segment: CUR Foreign Currency Information Position: 050 Loop: Level: Heading Usage: Optional Max Use: 1 Purpose: To specify the currency (dollars, pounds, francs, etc.) used in a transaction Syntax Notes: 1 If CUR08 is present, then CUR07 is required. 2 If CUR09 is present, then CUR07 is required. 3 If CUR10 is present, then at least one of CUR11 or CUR12 is required. 4 If CUR11 is present, then CUR10 is required. 5 If CUR12 is present, then CUR10 is required. 6 If CUR13 is present, then at least one of CUR14 or CUR15 is required. 7 If CUR14 is present, then CUR13 is required. 8 If CUR15 is present, then CUR13 is required. 9 If CUR16 is present, then at least one of CUR17 or CUR18 is required. 10 If CUR17 is present, then CUR16 is required. 11 If CUR18 is present, then CUR16 is required. 12 If CUR19 is present, then at least one of CUR20 or CUR21 is required. 13 If CUR20 is present, then CUR19 is required. 14 If CUR21 is present, then CUR19 is required. Semantic Notes: Comments: 1 See Figures Appendix for examples detailing the use of the CUR segment. Usage Notes: CIGNA may provide this segment in some situations. Notes: Use the CUR segment in the 835 to specify the currency and exchange rate, if applicable, when the payment is not being made in United States dollars or when the payment is made in a currency different from that in the original claim. Example: CUR*PR*CAN*1.2~ Data Element Summary Ref. Data Des. Element Name Attributes M CUR01 98 Entity Identifier Code M ID 2/3 Code identifying an organizational entity, a physical location, property or an individual INDUSTRY: Entity Identifier Code PR Payer REQUIRED M CUR Currency Code M ID 3/3 Code (Standard ISO) for country in whose currency the charges are specified INDUSTRY: Currency Code Used CUR Exchange Rate O R 4/10 Value to be used as a multiplier conversion factor to convert monetary value from one currency to another Use this element when the currency for payment is not the same as the currency specified in the original claims submitted for payment. For instance, when the claims were submitted in United States (US) dollars and paid in Canadian dollars, present the exchange rate from US dollars to Canadian dollars here. INDUSTRY: Exchange Rate Not Used CUR04 98 Entity Identifier Code O ID 2/3 Code identifying an organizational entity, a physical location, property or an 835CIGNA (004010X091A1) 13 December 30, 2002

14 individual Not Used CUR Currency Code O ID 3/3 Code (Standard ISO) for country in whose currency the charges are specified Not Used CUR Currency Market/Exchange Code O ID 3/3 Code identifying the market upon which the currency exchange rate is based Not Used CUR Date/Time Qualifier X ID 3/3 Code specifying type of date or time, or both date and time Not Used CUR Date O DT 8/8 Date expressed as CCYYMMDD Not Used CUR Time O TM 4/8 Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99) Not Used CUR Date/Time Qualifier X ID 3/3 Code specifying type of date or time, or both date and time Not Used CUR Date X DT 8/8 Date expressed as CCYYMMDD Not Used CUR Time X TM 4/8 Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99) Not Used CUR Date/Time Qualifier X ID 3/3 Code specifying type of date or time, or both date and time Not Used CUR Date X DT 8/8 Date expressed as CCYYMMDD Not Used CUR Time X TM 4/8 Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99) Not Used CUR Date/Time Qualifier X ID 3/3 Code specifying type of date or time, or both date and time 835CIGNA (004010X091A1) 14 December 30, 2002

15 Not Used CUR Date X DT 8/8 Date expressed as CCYYMMDD Not Used CUR Time X TM 4/8 Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99) Not Used CUR Date/Time Qualifier X ID 3/3 Code specifying type of date or time, or both date and time Not Used CUR Date X DT 8/8 Date expressed as CCYYMMDD Not Used CUR Time X TM 4/8 Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99) 835CIGNA (004010X091A1) 15 December 30, 2002

16 Segment: REF Receiver Identification Position: 060 Loop: Level: Heading Usage: Optional (Must Use) Max Use: 1 Purpose: To specify identifying information Syntax Notes: 1 At least one of REF02 or REF03 is required. 2 If either C04003 or C04004 is present, then the other is required. 3 If either C04005 or C04006 is present, then the other is required. Semantic Notes: 1 REF04 contains data relating to the value cited in REF02. Comments: Usage Notes: CIGNA will always provide this segment. Notes: Use this segment only when the receiver of the transaction is other than the payee (e.g., Clearing House or billing service ID). Example: REF*EV* ~ Data Element Summary Ref. Data Des. Element Name Attributes M REF Reference Identification Qualifier M ID 2/3 Code qualifying the Reference Identification INDUSTRY: Reference Identification Qualifier EV Receiver Identification Number A unique number identifying the organization/site location designated to receive the current transmitted transaction set M REF Reference Identification M AN 1/30 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier ALIAS: Receiver Identification INDUSTRY: Receiver Identifier Not Used REF Description X AN 1/80 A free-form description to clarify the related data elements and their content Not Used REF04 C040 Reference Identifier O To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier Not Used C Reference Identification Qualifier M ID 2/3 Code qualifying the Reference Identification Not Used C Reference Identification M AN 1/30 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Not Used C Reference Identification Qualifier X ID 2/3 Code qualifying the Reference Identification 835CIGNA (004010X091A1) 16 December 30, 2002

17 Not Used C Reference Identification X AN 1/30 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Not Used C Reference Identification Qualifier X ID 2/3 Code qualifying the Reference Identification Not Used C Reference Identification X AN 1/30 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 835CIGNA (004010X091A1) 17 December 30, 2002

18 Segment: REF Version Identification Position: 060 Loop: Level: Heading Usage: Optional Max Use: 1 Purpose: To specify identifying information Syntax Notes: 1 At least one of REF02 or REF03 is required. 2 If either C04003 or C04004 is present, then the other is required. 3 If either C04005 or C04006 is present, then the other is required. Semantic Notes: 1 REF04 contains data relating to the value cited in REF02. Comments: Usage Notes: CIGNA may provide this segment in some situations. Notes: Use this Reference Number Segment to report the version number of the adjudication system that generated the claim payments in this transaction. Update this reference number whenever a change in the version or release number affects the 835. (This is not the ANSI ASCX12 version number as reported in the GS segment.) Provide the version number when this information is required by the PAYER in order to resolve customer service questions from the PAYEE. Example: REF*F2*FS3.21~ Data Element Summary Ref. Data M Des. Element Name Attributes REF Reference Identification Qualifier M ID 2/3 Code qualifying the Reference Identification INDUSTRY: Reference Identification Qualifier F2 Version Code - Local Identifies the release of a set of information or requirements to distinguish from the previous or future sets that may differ; the release in question is on the local level M REF Reference Identification M AN 1/30 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Version Identification Code Not Used REF Description X AN 1/80 A free-form description to clarify the related data elements and their content Not Used REF04 C040 Reference Identifier O To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier Not Used C Reference Identification Qualifier M ID 2/3 Code qualifying the Reference Identification Not Used C Reference Identification M AN 1/30 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Not Used C Reference Identification Qualifier X ID 2/3 835CIGNA (004010X091A1) 18 December 30, 2002

19 Code qualifying the Reference Identification Not Used C Reference Identification X AN 1/30 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Not Used C Reference Identification Qualifier X ID 2/3 Code qualifying the Reference Identification Not Used C Reference Identification X AN 1/30 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 835CIGNA (004010X091A1) 19 December 30, 2002

20 Segment: DTM Production Date Position: 070 Loop: Level: Heading Usage: Optional (Must Use) Max Use: 1 Purpose: To specify pertinent dates and times Syntax Notes: 1 At least one of DTM02 DTM03 or DTM05 is required. 2 If DTM04 is present, then DTM03 is required. 3 If either DTM05 or DTM06 is present, then the other is required. Semantic Notes: Comments: Usage Notes: CIGNA will always provide this segment. Notes: The production date must be supplied when the cutoff date of the adjudication system is different from the date of the 835. Example: DTM*405* ~ Data Element Summary Ref. Data M Des. Element Name Attributes DTM Date/Time Qualifier M ID 3/3 Code specifying type of date or time, or both date and time INDUSTRY: Date Time Qualifier 405 Production Used to identify dates and times that operations or processes were performed Use this code for the end date for the adjudication production cycle for claims included in this 835. M DTM Date M DT 8/8 Date expressed as CCYYMMDD INDUSTRY: Production Date Not Used DTM Time X TM 4/8 Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99) Not Used DTM Time Code O ID 2/2 Code identifying the time. In accordance with International Standards Organization standard 8601, time can be specified by a + or - and an indication in hours in relation to Universal Time Coordinate (UTC) time; since + is a restricted character, + and - are substituted by P and M in the codes that follow Not Used DTM Date Time Period Format Qualifier X ID 2/3 Code indicating the date format, time format, or date and time format Not Used DTM Date Time Period X AN 1/35 Expression of a date, a time, or range of dates, times or dates and times 835CIGNA (004010X091A1) 20 December 30, 2002

21 Segment: N1 Payer Identification Position: 080 Loop: 1000A Mandatory Level: Heading Usage: Mandatory Max Use: 1 Purpose: To identify a party by type of organization, name, and code Syntax Notes: 1 At least one of N102 or N103 is required. 2 If either N103 or N104 is present, then the other is required. Semantic Notes: Comments: 1 This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party. Notes: 2 N105 and N106 further define the type of entity in N101. Use this N1 loop to provide the name/address information for the payer. The payer's secondary identifying reference number should be provided in N104, if necessary. CIGNA will always provide this segment. CIGNA does not utilize N103 (Identification code qualifier) and N104 (Identification Code) data elements in this segment. Example: N1*PR*INSURANCE COMPANY OF TIMBUCKTU*XV* ~ Data Element Summary Ref. Data M Des. Element Name Attributes N Entity Identifier Code M ID 2/3 Code identifying an organizational entity, a physical location, property or an individual INDUSTRY: Entity Identifier Code PR Payer Must Use N Name X AN 1/60 Free-form name Required if the National PlanID is not transmitted in N104. INDUSTRY: Payer Name Not Used N Identification Code Qualifier C ID 1/2 Code designating the system/method of code structure used for Identification Code (67) Required if the National PlanID is transmitted in N104. INDUSTRY: Identification Code Qualifier XV Health Care Financing Administration National Payer Identification Number (PAYERID) Required if the National PlanID is mandated for use. Not Used N Identification Code C AN 2/80 Code identifying a party or other code Required if the National PlanID is mandated for use. INDUSTRY: Payer Identifier Not Used N Entity Relationship Code O ID 2/2 Code describing entity relationship 835CIGNA (004010X091A1) 21 December 30, 2002

22 Not Used N Entity Identifier Code O ID 2/3 Code identifying an organizational entity, a physical location, property or an individual 835CIGNA (004010X091A1) 22 December 30, 2002

23 Segment: N3 Payer Address Position: 100 Loop: 1000A Mandatory Level: Heading Usage: Mandatory Max Use: 1 Purpose: To specify the location of the named party Syntax Notes: Semantic Notes: Comments: Notes: CIGNA will always provide this segment. Example: N3*100 MAIN STREET~ Data Element Summary Ref. Data M Des. Element Name Attributes N Address Information M AN 1/55 Address information INDUSTRY: Payer Address Line Used N Address Information O AN 1/55 Address information Required if a second address line exists. INDUSTRY: Payer Address Line 835CIGNA (004010X091A1) 23 December 30, 2002

24 Segment: N4 Payer City, State, ZIP Code Position: 110 Loop: 1000A Mandatory Level: Heading Usage: Mandatory Max Use: 1 Purpose: To specify the geographic place of the named party Syntax Notes: 1 If N406 is present, then N405 is required. Semantic Notes: Comments: 1 A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. Notes: 2 N402 is required only if city name (N401) is in the U.S. or Canada. CIGNA will always provide this segment. Example: N4*KANSAS CITY*MO*64108~ Data Element Summary Ref. Data M Des. Element Name Attributes N City Name M AN 2/30 Free-form text for city name INDUSTRY: Payer City Name M N State or Province Code M ID 2/2 Code (Standard State/Province) as defined by appropriate government agency INDUSTRY: Payer State Code M N Postal Code M ID 3/15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) INDUSTRY: Payer Postal Zone or ZIP Code Not Used N Country Code O ID 2/3 Code identifying the country Not Used N Location Qualifier X ID 1/2 Code identifying type of location Not Used N Location Identifier O AN 1/30 Code which identifies a specific location 835CIGNA (004010X091A1) 24 December 30, 2002

25 Segment: REF Additional Payer Identification Position: 120 Loop: 1000A Mandatory Level: Heading Usage: Optional Max Use: 4 Purpose: To specify identifying information Syntax Notes: 1 At least one of REF02 or REF03 is required. 2 If either C04003 or C04004 is present, then the other is required. 3 If either C04005 or C04006 is present, then the other is required. Semantic Notes: 1 REF04 contains data relating to the value cited in REF02. Comments: Usage Notes: CIGNA may provide this segment in some situations. Notes: Use this REF segment whenever additional payer identification numbers are required. The ID numbers available in the TRN and N1 segments should be used before using the REF segment. Example: REF*2U*98765~ Data Element Summary Ref. Data Des. Element Name Attributes M REF Reference Identification Qualifier M ID 2/3 Code qualifying the Reference Identification INDUSTRY: Reference Identification Qualifier 2U Payer Identification Number For Medicare carriers or intermediaries, use this number for the Medicare carrier or intermediary ID number. For Blue Cross and Blue Shield Plans, use this number for the Blue Cross Blue Shield association plan code. EO Submitter Identification Number A unique number identifying the submitter of the transaction set This should be considered required when the transaction sender is not the payer or is identified by an identifier other than those already provided. HI Health Industry Number (HIN) NF National Association of Insurance Commissioners (NAIC) Code A unique number assigned to each insurance company ADVISED M REF Reference Identification M AN 1/30 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier INDUSTRY: Additional Payer Identifier Not Used REF Description X AN 1/80 A free-form description to clarify the related data elements and their content Not Used REF04 C040 Reference Identifier O To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier Not Used C Reference Identification Qualifier M ID 2/3 Code qualifying the Reference Identification 835CIGNA (004010X091A1) 25 December 30, 2002

26 Not Used C Reference Identification M AN 1/30 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Not Used C Reference Identification Qualifier X ID 2/3 Code qualifying the Reference Identification Not Used C Reference Identification X AN 1/30 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Not Used C Reference Identification Qualifier X ID 2/3 Code qualifying the Reference Identification Not Used C Reference Identification X AN 1/30 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 835CIGNA (004010X091A1) 26 December 30, 2002

27 Segment: N1 Payee Identification Position: 080 Loop: 1000B Mandatory Level: Heading Usage: Mandatory Max Use: 1 Purpose: To identify a party by type of organization, name, and code Syntax Notes: 1 At least one of N102 or N103 is required. 2 If either N103 or N104 is present, then the other is required. Semantic Notes: Comments: 1 This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party. 2 N105 and N106 further define the type of entity in N101. Notes: Use this N1 loop to provide the name/address information of the payee. The identifying reference number should be provided in N104. CIGNA will always provide this segment. Example: N1*PE*CYBILS MENTAL HOSPITAL*XX* ~ Data Element Summary Ref. Data M Des. Element Name Attributes N Entity Identifier Code M ID 2/3 Code identifying an organizational entity, a physical location, property or an individual INDUSTRY: Entity Identifier Code PE Payee Used N Name X AN 1/60 Free-form name Required when N104 does not contain the National Provider Identifier. INDUSTRY: Payee Name M N Identification Code Qualifier M ID 1/2 Code designating the system/method of code structure used for Identification Code (67) Required when N104 does not contain the National Provider Identifier. INDUSTRY: Identification Code Qualifier FI Federal Taxpayer's Identification Number For individual providers as payees, use this number to represent the Social Security Number. XX Health Care Financing Administration National Provider Identifier M N Identification Code M AN 2/80 Code identifying a party or other code INDUSTRY: Payee Identification Code Not Used N Entity Relationship Code O ID 2/2 Code describing entity relationship Not Used N Entity Identifier Code O ID 2/3 835CIGNA (004010X091A1) 27 December 30, 2002

28 Code identifying an organizational entity, a physical location, property or an individual 835CIGNA (004010X091A1) 28 December 30, 2002

29 Segment: N3 Payee Address Position: 100 Loop: 1000B Mandatory Level: Heading Usage: Optional (Must Use) Max Use: 1 Purpose: To specify the location of the named party Syntax Notes: Semantic Notes: Comments: Usage Notes: CIGNA will always provide this segment. Notes: Use of this segment is at the discretion of the payer for situations where the sender needs to communicate the payee address to a transaction receiver (for example, a VAB or a Clearinghouse). Example: N3*Suite 200*1000 Main Street~ Data Element Summary Ref. Data M Des. Element Name Attributes N Address Information M AN 1/55 Address information INDUSTRY: Payee Address Line Used N Address Information O AN 1/55 Address information Required if a second address line exists. INDUSTRY: Payee Address Line 835CIGNA (004010X091A1) 29 December 30, 2002

30 Segment: N4 Payee City, State, ZIP Code Position: 110 Loop: 1000B Mandatory Level: Heading Usage: Optional (Must Use) Max Use: 1 Purpose: To specify the geographic place of the named party Syntax Notes: 1 If N406 is present, then N405 is required. Semantic Notes: Comments: 1 A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. Usage Notes: 2 N402 is required only if city name (N401) is in the U.S. or Canada. CIGNA will always provide this segment. Notes: Using this segment is at the discretion of the payer contingent on the business needs of the payee (receiver). Example: N4*Beverly Hills*CA*90210~ Data Element Summary Ref. Data M Des. Element Name Attributes N City Name M AN 2/30 Free-form text for city name INDUSTRY: Payee City Name M N State or Province Code M ID 2/2 Code (Standard State/Province) as defined by appropriate government agency INDUSTRY: Payee State Code M N Postal Code M ID 3/15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) INDUSTRY: Payee Postal Zone or ZIP Code Used N Country Code O ID 2/3 Code identifying the country Required if country is other than USA. INDUSTRY: Country Code Not Used N Location Qualifier X ID 1/2 Code identifying type of location Not Used N Location Identifier O AN 1/30 Code which identifies a specific location 835CIGNA (004010X091A1) 30 December 30, 2002

31 Segment: REF Payee Additional Identification Position: 120 Loop: 1000B Mandatory Level: Heading Usage: Optional Max Use: >1 Purpose: To specify identifying information Syntax Notes: 1 At least one of REF02 or REF03 is required. 2 If either C04003 or C04004 is present, then the other is required. 3 If either C04005 or C04006 is present, then the other is required. Semantic Notes: 1 REF04 contains data relating to the value cited in REF02. Comments: Usage Notes: CIGNA may provide this segment in some situations. Notes: Use this REF segment only when more than one identification number is required to identify the payee. Always use the ID number available in the N1 segment before using the REF segment. CIGNA utilizes up to 10 occurrences of Payee Additional Identification segment Example: REF*PQ* ~ Data Element Summary Ref. Data Des. Element Name Attributes M REF Reference Identification Qualifier M ID 2/3 Code qualifying the Reference Identification INDUSTRY: Reference Identification Qualifier 0B State License Number 1A Blue Cross Provider Number NOT ADVISED 1B Blue Shield Provider Number NOT ADVISED 1C Medicare Provider Number NOT ADVISED 1D Medicaid Provider Number NOT ADVISED 1E Dentist License Number NOT ADVISED 1F Anesthesia License Number NOT ADVISED 1G Provider UPIN Number 1H CHAMPUS Identification Number NOT ADVISED D3 National Association of Boards of Pharmacy Number G2 Provider Commercial Number A unique number assigned to a provider by a commercial insurer NOT ADVISED N5 Provider Plan Network Identification Number A number assigned to identify a specific provider in a health care plan network NOT ADVISED PQ Payee Identification TJ Federal Taxpayer's Identification Number 835CIGNA (004010X091A1) 31 December 30, 2002