1<?xml version="1.0" encoding="utf-8"?> 2<!-- 3###################################################################### 4# Copyright (c) 5# John Holland <john@zoner.org> 6# All rights reserved. 7# 8# This software is licensed as described in the file LICENSE.txt, which 9# you should have received as part of this distribution. 10# 11###################################################################### 12--> 13<transaction xid="835W1" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:noNamespaceSchemaLocation="map.xsd"> 14 <name>HIPAA Health Care Claim Payment/Advice 005010X221A1 835W1</name> 15 <loop xid="ISA_LOOP" type="explicit"> 16 <name>Interchange Control Header</name> 17 <usage>R</usage> 18 <pos>0010</pos> 19 <repeat>>1</repeat> 20 <segment xid="ISA"> 21 <name>Interchange Control Header</name> 22 <usage>R</usage> 23 <pos>0100</pos> 24 <max_use>1</max_use> 25 <element xid="ISA01"> 26 <data_ele>I01</data_ele> 27 <name>Authorization Information Qualifier</name> 28 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<seq>19</seq> 1672 </element> 1673 </segment> 1674 <!--End of TS2 segment--> 1675 <loop xid="2100"> 1676 <name>Claim Payment Information</name> 1677 <usage>R</usage> 1678 <pos>0100</pos> 1679 <repeat>>1</repeat> 1680 <segment xid="CLP"> 1681 <name>Claim Payment Information</name> 1682 <usage>R</usage> 1683 <pos>0100</pos> 1684 <max_use>1</max_use> 1685 <element xid="CLP01"> 1686 <data_ele>1028</data_ele> 1687 <name>Patient Control Number</name> 1688 <usage>R</usage> 1689 <seq>01</seq> 1690 </element> 1691 <element xid="CLP02"> 1692 <data_ele>1029</data_ele> 1693 <name>Claim Status Code</name> 1694 <usage>R</usage> 1695 <seq>02</seq> 1696 <valid_codes> 1697 <code>1</code> 1698 <code>19</code> 1699 <code>2</code> 1700 <code>20</code> 1701 <code>21</code> 1702 <code>22</code> 1703 <code>23</code> 1704 <code>25</code> 1705 <code>3</code> 1706 <code>4</code> 1707 </valid_codes> 1708 </element> 1709 <element xid="CLP03"> 1710 <data_ele>782</data_ele> 1711 <name>Total Claim Charge Amount</name> 1712 <usage>R</usage> 1713 <seq>03</seq> 1714 </element> 1715 <element xid="CLP04"> 1716 <data_ele>782</data_ele> 1717 <name>Claim Payment Amount</name> 1718 <usage>R</usage> 1719 <seq>04</seq> 1720 </element> 1721 <element xid="CLP05"> 1722 <data_ele>782</data_ele> 1723 <name>Patient Responsibility Amount</name> 1724 <usage>S</usage> 1725 <seq>05</seq> 1726 </element> 1727 <element xid="CLP06"> 1728 <data_ele>1032</data_ele> 1729 <name>Claim Filing Indicator Code</name> 1730 <usage>R</usage> 1731 <seq>06</seq> 1732 <valid_codes> 1733 <code>12</code> 1734 <code>13</code> 1735 <code>14</code> 1736 <code>15</code> 1737 <code>16</code> 1738 <code>17</code> 1739 <code>AM</code> 1740 <code>CH</code> 1741 <code>DS</code> 1742 <code>HM</code> 1743 <code>LM</code> 1744 <code>MA</code> 1745 <code>MB</code> 1746 <code>MC</code> 1747 <code>OF</code> 1748 <code>TV</code> 1749 <code>VA</code> 1750 <code>WC</code> 1751 <code>ZZ</code> 1752 </valid_codes> 1753 </element> 1754 <element xid="CLP07"> 1755 <data_ele>127</data_ele> 1756 <name>Payer Claim Control Number</name> 1757 <usage>R</usage> 1758 <seq>07</seq> 1759 </element> 1760 <element xid="CLP08"> 1761 <data_ele>1331</data_ele> 1762 <name>Facility Type Code</name> 1763 <usage>S</usage> 1764 <seq>08</seq> 1765 </element> 1766 <element xid="CLP09"> 1767 <data_ele>1325</data_ele> 1768 <name>Claim Frequency Code</name> 1769 <usage>S</usage> 1770 <seq>09</seq> 1771 </element> 1772 <element xid="CLP10"> 1773 <data_ele>1352</data_ele> 1774 <name>Patient Status Code</name> 1775 <usage>N</usage> 1776 <seq>10</seq> 1777 </element> 1778 <element xid="CLP11"> 1779 <data_ele>1354</data_ele> 1780 <name>Diagnosis Related Group (DRG) Code</name> 1781 <usage>S</usage> 1782 <seq>11</seq> 1783 </element> 1784 <element xid="CLP12"> 1785 <data_ele>380</data_ele> 1786 <name>Diagnosis Related Group (DRG) Weight</name> 1787 <usage>S</usage> 1788 <seq>12</seq> 1789 </element> 1790 <element xid="CLP13"> 1791 <data_ele>954</data_ele> 1792 <name>Discharge Fraction</name> 1793 <usage>S</usage> 1794 <seq>13</seq> 1795 </element> 1796 <element xid="CLP14"> 1797 <data_ele>1073</data_ele> 1798 <name>Yes/No Condition or Response Code</name> 1799 <usage>N</usage> 1800 <seq>14</seq> 1801 </element> 1802 </segment> 1803 <!--End of CLP segment--> 1804 <segment xid="CAS"> 1805 <name>Claim Adjustment</name> 1806 <usage>S</usage> 1807 <pos>0200</pos> 1808 <max_use>99</max_use> 1809 <syntax>L050607</syntax> 1810 <syntax>C0605</syntax> 1811 <syntax>C0705</syntax> 1812 <syntax>L080910</syntax> 1813 <syntax>C0908</syntax> 1814 <syntax>C1008</syntax> 1815 <syntax>L111213</syntax> 1816 <syntax>C1211</syntax> 1817 <syntax>C1311</syntax> 1818 <syntax>L141516</syntax> 1819 <syntax>C1514</syntax> 1820 <syntax>C1614</syntax> 1821 <syntax>L171819</syntax> 1822 <syntax>C1817</syntax> 1823 <syntax>C1917</syntax> 1824 <element xid="CAS01"> 1825 <data_ele>1033</data_ele> 1826 <name>Claim Adjustment Group Code</name> 1827 <usage>R</usage> 1828 <seq>01</seq> 1829 <valid_codes> 1830 <code>CO</code> 1831 <code>OA</code> 1832 <code>PI</code> 1833 <code>PR</code> 1834 </valid_codes> 1835 </element> 1836 <element xid="CAS02"> 1837 <data_ele>1034</data_ele> 1838 <name>Adjustment Reason Code</name> 1839 <usage>R</usage> 1840 <seq>02</seq> 1841 <valid_codes external="adjustment_reason" /> 1842 </element> 1843 <element xid="CAS03"> 1844 <data_ele>782</data_ele> 1845 <name>Adjustment Amount</name> 1846 <usage>R</usage> 1847 <seq>03</seq> 1848 </element> 1849 <element xid="CAS04"> 1850 <data_ele>380</data_ele> 1851 <name>Adjustment Quantity</name> 1852 <usage>S</usage> 1853 <seq>04</seq> 1854 </element> 1855 <element xid="CAS05"> 1856 <data_ele>1034</data_ele> 1857 <name>Adjustment Reason Code</name> 1858 <usage>S</usage> 1859 <seq>05</seq> 1860 <valid_codes external="adjustment_reason" /> 1861 </element> 1862 <element xid="CAS06"> 1863 <data_ele>782</data_ele> 1864 <name>Adjustment Amount</name> 1865 <usage>S</usage> 1866 <seq>06</seq> 1867 </element> 1868 <element xid="CAS07"> 1869 <data_ele>380</data_ele> 1870 <name>Adjustment Quantity</name> 1871 <usage>S</usage> 1872 <seq>07</seq> 1873 </element> 1874 <element xid="CAS08"> 1875 <data_ele>1034</data_ele> 1876 <name>Adjustment Reason Code</name> 1877 <usage>S</usage> 1878 <seq>08</seq> 1879 <valid_codes external="adjustment_reason" /> 1880 </element> 1881 <element xid="CAS09"> 1882 <data_ele>782</data_ele> 1883 <name>Adjustment Amount</name> 1884 <usage>S</usage> 1885 <seq>09</seq> 1886 </element> 1887 <element xid="CAS10"> 1888 <data_ele>380</data_ele> 1889 <name>Adjustment Quantity</name> 1890 <usage>S</usage> 1891 <seq>10</seq> 1892 </element> 1893 <element xid="CAS11"> 1894 <data_ele>1034</data_ele> 1895 <name>Adjustment Reason Code</name> 1896 <usage>S</usage> 1897 <seq>11</seq> 1898 <valid_codes external="adjustment_reason" /> 1899 </element> 1900 <element xid="CAS12"> 1901 <data_ele>782</data_ele> 1902 <name>Adjustment Amount</name> 1903 <usage>S</usage> 1904 <seq>12</seq> 1905 </element> 1906 <element xid="CAS13"> 1907 <data_ele>380</data_ele> 1908 <name>Adjustment Quantity</name> 1909 <usage>S</usage> 1910 <seq>13</seq> 1911 </element> 1912 <element xid="CAS14"> 1913 <data_ele>1034</data_ele> 1914 <name>Adjustment Reason Code</name> 1915 <usage>S</usage> 1916 <seq>14</seq> 1917 <valid_codes external="adjustment_reason" /> 1918 </element> 1919 <element xid="CAS15"> 1920 <data_ele>782</data_ele> 1921 <name>Adjustment Amount</name> 1922 <usage>S</usage> 1923 <seq>15</seq> 1924 </element> 1925 <element xid="CAS16"> 1926 <data_ele>380</data_ele> 1927 <name>Adjustment Quantity</name> 1928 <usage>S</usage> 1929 <seq>16</seq> 1930 </element> 1931 <element xid="CAS17"> 1932 <data_ele>1034</data_ele> 1933 <name>Adjustment Reason Code</name> 1934 <usage>S</usage> 1935 <seq>17</seq> 1936 <valid_codes external="adjustment_reason" /> 1937 </element> 1938 <element xid="CAS18"> 1939 <data_ele>782</data_ele> 1940 <name>Adjustment Amount</name> 1941 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<data_ele>66</data_ele> 2292 <name>Identification Code Qualifier</name> 2293 <usage>R</usage> 2294 <seq>08</seq> 2295 <valid_codes> 2296 <code>BD</code> 2297 <code>BS</code> 2298 <code>FI</code> 2299 <code>MC</code> 2300 <code>PC</code> 2301 <code>SL</code> 2302 <code>UP</code> 2303 <code>XX</code> 2304 </valid_codes> 2305 </element> 2306 <element xid="NM109"> 2307 <data_ele>67</data_ele> 2308 <name>Rendering Provider Identifier</name> 2309 <usage>R</usage> 2310 <seq>09</seq> 2311 </element> 2312 <element xid="NM110"> 2313 <data_ele>706</data_ele> 2314 <name>Entity Relationship Code</name> 2315 <usage>N</usage> 2316 <seq>10</seq> 2317 </element> 2318 <element xid="NM111"> 2319 <data_ele>98</data_ele> 2320 <name>Entity Identifier Code</name> 2321 <usage>N</usage> 2322 <seq>11</seq> 2323 </element> 2324 <element xid="NM112"> 2325 <data_ele>1035</data_ele> 2326 <name>Name Last or Organization Name</name> 2327 <usage>N</usage> 2328 <seq>12</seq> 2329 </element> 2330 </segment> 2331 <!--End 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