835 HIPAA Health Care Claim Payment/Advice X091-835 Interchange Control Header R 001 >1 Interchange Control Header R 010 1 I01 Authorization Information Qualifier R 01 ID 2 2 00 03 I02 Authorization Information R 02 AN 10 10 I03 Security Information Qualifier R 03 ID 2 2 00 01 I04 Security Information R 04 AN 10 10 I05 Interchange ID Qualifier R 05 ID 2 2 01 14 20 27 28 29 30 33 ZZ I06 Interchange Sender ID R 06 AN 15 15 I05 Interchange ID Qualifier R 07 ID 2 2 01 14 20 27 28 29 30 33 ZZ I07 Interchange Receiver ID R 08 AN 15 15 I08 Interchange Date R 09 DT 6 6 I09 Interchange Time R 10 TM 4 4 I10 Interchange Control Standards Identifier R 11 ID 1 1 U I11 Interchange Control Version Number R 12 ID 5 5 00401 I12 Interchange Control Number R 13 N0 9 9 I13 Acknowledgment Requested R 14 ID 1 1 0 1 I14 Usage Indicator R 15 ID 1 1 P T I15 Component Element Separator R 16 AN 1 1 Functional Group Header R 020 >1 Functional Group Header R 010 1 479 Functional Identifier Code R 01 ID 2 2 HP 142 Application Sender's Code R 02 AN 2 15 124 Application Receiver's Code R 03 AN 2 15 373 Date R 04 DT 8 8 337 Time R 05 TM 4 8 28 Group Control Number R 06 N0 1 9 455 Responsible Agency Code R 07 ID 1 2 X 480 Version / Release / Industry Identifier Code R 08 AN 1 12 004010X091A1 Transaction Set Header R 020 >1 Transaction Set Header R 010 1 143 Transaction Set Identifier Code R 01 ID 3 3 835 329 Transaction Set Control Number R 02 AN 4 9 Table 1 - Header R 015 1 Financial Information R 020 1 305 Transaction Handling Code R 01 ID 1 2 C D H I P U X 782 Total Actual Provider Payment Amount R 02 R 1 18 478 Credit or Debit Flag Code R 03 ID 1 1 C D 591 Payment Method Code R 04 ID 3 3 ACH BOP CHK FWT NON 812 Payment Format Code S 05 ID 1 10 CCP CTX 506 Depository Financial Institution (DFI) Identification Number Qualifier S 06 ID 2 2 01 04 507 Sender DFI Identifier S 07 AN 3 12 569 Account Number Qualifier S 08 ID 1 3 DA 508 Sender Bank Account Number S 09 AN 1 35 509 Payer Identifier S 10 AN 10 10 510 Originating Company Supplemental Code S 11 AN 9 9 506 Depository Financial Institution (DFI) Identification Number Qualifier S 12 ID 2 2 01 04 507 Receiver or Provider Bank ID Number S 13 AN 3 12 569 Account Number Qualifier S 14 ID 1 3 DA SG 508 Receiver or Provider Account Number S 15 AN 1 35 373 Check Issue or EFT Effective Date R 16 DT 8 8 1048 Business Function Code N 17 ID 1 3 506 (DFI) ID Number Qualifier N 18 ID 2 2 507 (DFI) Identification Number N 19 AN 3 12 569 Account Number Qualifier N 20 ID 1 3 508 Account Number N 21 AN 1 35 Reassociation Trace Number R 040 1 481 Trace Type Code R 01 ID 1 2 1 127 Check or EFT Trace Number R 02 AN 1 30 509 Payer Identifier R 03 AN 10 10 127 Originating Company Supplemental Code S 04 AN 1 30 Foreign Currency Information S 050 1 98 Entity Identifier Code R 01 ID 2 3 PR 100 Currency Code R 02 ID 3 3 280 Exchange Rate S 03 R 4 10 98 Entity Identifier Code N 04 ID 2 3 100 Currency Code N 05 ID 3 3 669 Currency Market/Exchange Code N 06 ID 3 3 374 Date/Time Qualifier N 07 ID 3 3 373 Date N 08 DT 8 8 337 Time N 09 TM 4 8 374 Date/Time Qualifier N 10 ID 3 3 373 Date N 11 DT 8 8 337 Time N 12 TM 4 8 374 Date/Time Qualifier N 13 ID 3 3 373 Date N 14 DT 8 8 337 Time N 15 TM 4 8 374 Date/Time Qualifier N 16 ID 3 3 373 Date N 17 DT 8 8 337 Time N 18 TM 4 8 374 Date/Time Qualifier N 19 ID 3 3 373 Date N 20 DT 8 8 337 Time N 21 TM 4 8 Receiver Identification S 060 1 128 Reference Identification Qualifier R 01 ID 2 3 EV 127 Receiver Identifier R 02 AN 1 30 352 Description N 03 AN 1 80 C040 Reference Identifier N 04 Version Identification S 060 1 128 Reference Identification Qualifier R 01 ID 2 3 F2 127 Version Identification Code R 02 AN 1 30 352 Description N 03 AN 1 80 C040 Reference Identifier N 04 Production Date S 070 1 374 Date Time Qualifier R 01 ID 3 3 405 373 Production Date R 02 DT 8 8 337 Time N 03 TM 4 8 623 Time Code N 04 ID 2 2 1250 Date Time Period Format Qualifier N 05 ID 2 3 1251 Date Time Period N 06 AN 1 35 Payer Identification R 080 1 Payer Identification R 080 1 98 Entity Identifier Code R 01 ID 2 3 PR 93 Payer Name S 02 AN 1 60 66 Identification Code Qualifier S 03 ID 1 2 XV 67 Payer Identifier S 04 AN 2 80 706 Entity Relationship Code N 05 ID 2 2 98 Entity Identifier Code N 06 ID 2 3 Payer Address R 100 1 166 Payer Address Line R 01 AN 1 55 166 Payer Address Line S 02 AN 1 55 Payer City, State, ZIP Code R 110 1 19 Payer City Name R 01 AN 2 30 156 Payer State Code R 02 ID 2 2 116 Payer Postal Zone or ZIP Code R 03 ID 3 15 26 Country Code N 04 ID 2 3 309 Location Qualifier N 05 ID 1 2 310 Location Identifier N 06 AN 1 30 Additional Payer Identification S 120 4 128 Reference Identification Qualifier R 01 ID 2 3 2U EO HI NF 127 Additional Payer Identifier R 02 AN 1 30 352 Description N 03 AN 1 80 C040 Reference Identifier N 04 Payer Contact Information S 130 1 366 Contact Function Code R 01 ID 2 2 CX 93 Payer Contact Name S 02 AN 1 60 365 Communication Number Qualifier S 03 ID 2 2 EM FX TE 364 Payer Contact Communication Number S 04 AN 1 80 365 Communication Number Qualifier S 05 ID 2 2 EM EX FX TE 364 Payer Contact Communication Number S 06 AN 1 80 365 Communication Number Qualifier S 07 ID 2 2 EX 364 Payer Contact Communication Number S 08 AN 1 80 443 Contact Inquiry Reference N 09 AN 1 20 Payee Identification R 080 1 Payee Identification R 080 1 98 Entity Identifier Code R 01 ID 2 3 PE 93 Payee Name S 02 AN 1 60 66 Identification Code Qualifier R 03 ID 1 2 FI XX 67 Payee Identification Code R 04 AN 2 80 706 Entity Relationship Code N 05 ID 2 2 98 Entity Identifier Code N 06 ID 2 3 Payee Address S 100 1 166 Payee Address Line R 01 AN 1 55 166 Payee Address Line S 02 AN 1 55 Payee City, State, ZIP Code S 110 1 19 Payee City Name R 01 AN 2 30 156 Payee State Code R 02 ID 2 2 116 Payee Postal Zone or ZIP Code R 03 ID 3 15 26 Country Code S 04 ID 2 3 309 Location Qualifier N 05 ID 1 2 310 Location Identifier N 06 AN 1 30 Payee Additional Identification S 120 >1 128 Reference Identification Qualifier R 01 ID 2 3 0B 1A 1B 1C 1D 1E 1F 1G 1H D3 G2 N5 PQ TJ 127 Additional Payee Identifier R 02 AN 1 30 352 Description N 03 AN 1 80 C040 Reference Identifier N 04 Table 2 - Detail S 020 >1 Header Number S 003 >1 Header Number R 003 1 554 Assigned Number R 01 N0 1 6 Provider Summary Information S 005 1 127 Provider Identifier R 01 AN 1 30 1331 Facility Type Code R 02 AN 1 2 373 Fiscal Period Date R 03 DT 8 8 380 Total Claim Count R 04 R 1 15 782 Total Claim Charge Amount R 05 R 1 18 782 Total Covered Charge Amount S 06 R 1 18 782 Total Noncovered Charge Amount S 07 R 1 18 782 Total Denied Charge Amount S 08 R 1 18 782 Total Provider Payment Amount S 09 R 1 18 782 Total Interest Amount S 10 R 1 18 782 Total Contractual Adjustment Amount S 11 R 1 18 782 Total Gramm-Rudman Reduction Amount S 12 R 1 18 782 Total MSP Payer Amount S 13 R 1 18 782 Total Blood Deductible Amount S 14 R 1 18 782 Total Non-Lab Charge Amount S 15 R 1 18 782 Total Coinsurance Amount S 16 R 1 18 782 Total HCPCS Reported Charge Amount S 17 R 1 18 782 Total HCPCS Payable Amount S 18 R 1 18 782 Total Deductible Amount S 19 R 1 18 782 Total Professional Component Amount S 20 R 1 18 782 Total MSP Patient Liability Met Amount S 21 R 1 18 782 Total Patient Reimbursement Amount S 22 R 1 18 380 Total PIP Claim Count S 23 R 1 15 782 Total PIP Adjustment Amount S 24 R 1 18 Provider Supplemental Summary Information S 007 1 782 Total DRG Amount S 01 R 1 18 782 Total Federal Specific Amount S 02 R 1 18 782 Total Hospital Specific Amount S 03 R 1 18 782 Total Disproportionate Share Amount S 04 R 1 18 782 Total Capital Amount S 05 R 1 18 782 Total Indirect Medical Education Amount S 06 R 1 18 380 Total Outlier Day Count S 07 R 1 15 782 Total Day Outlier Amount S 08 R 1 18 782 Total Cost Outlier Amount S 09 R 1 18 380 Average DRG Length of Stay S 10 R 1 15 380 Total Discharge Count S 11 R 1 15 380 Total Cost Report Day Count S 12 R 1 15 380 Total Covered Day Count S 13 R 1 15 380 Total Noncovered Day Count S 14 R 1 15 782 Total MSP Pass-Through Amount S 15 R 1 18 380 Average DRG weight S 16 R 1 15 782 Total PPS Capital FSP DRG Amount S 17 R 1 18 782 Total PPS Capital HSP DRG Amount S 18 R 1 18 782 Total PPS DSH DRG Amount S 19 R 1 18 Claim Payment Information R 010 >1 Claim Payment Information R 010 1 1028 Patient Control Number R 01 AN 1 38 1029 Claim Status Code R 02 ID 1 2 782 Total Claim Charge Amount R 03 R 1 18 782 Claim Payment Amount R 04 R 1 18 782 Patient Responsibility Amount S 05 R 1 18 1032 Claim Filing Indicator Code R 06 ID 1 2 12 13 14 15 16 AM CH DS HM LM MA MB MC OF TV VA WC 127 Payer Claim Control Number S 07 AN 1 30 1331 Facility Type Code S 08 AN 1 2 1325 Claim Frequency Code S 09 ID 1 1 0 1 2 3 4 5 6 7 8 9 A B C D E F G H I J K L M N O X Y Z 1352 Patient Status Code N 10 ID 1 2 1354 Diagnosis Related Group (DRG) Code S 11 ID 1 4 380 Diagnosis Related Group (DRG) Weight S 12 R 1 15 954 Discharge Fraction S 13 R 1 10 Claim Adjustment S 020 99 1033 Claim Adjustment Group Code R 01 ID 1 2 CO CR OA PI PR 1034 Adjustment Reason Code R 02 ID 1 5 782 Adjustment Amount R 03 R 1 18 380 Adjustment Quantity S 04 R 1 15 1034 Adjustment Reason Code S 05 ID 1 5 782 Adjustment Amount S 06 R 1 18 380 Adjustment Quantity S 07 R 1 15 1034 Adjustment Reason Code S 08 ID 1 5 782 Adjustment Amount S 09 R 1 18 380 Adjustment Quantity S 10 R 1 15 1034 Adjustment Reason Code S 11 ID 1 5 782 Adjustment Amount S 12 R 1 18 380 Adjustment Quantity S 13 R 1 15 1034 Adjustment Reason Code S 14 ID 1 5 782 Adjustment Amount S 15 R 1 18 380 Adjustment Quantity S 16 R 1 15 1034 Adjustment Reason Code S 17 ID 1 5 782 Adjustment Amount S 18 R 1 18 380 Adjustment Quantity S 19 R 1 15 Patient Name R 030 1 98 Entity Identifier Code R 01 ID 2 3 QC 1065 Entity Type Qualifier R 02 ID 1 1 1 1035 Patient Last Name R 03 AN 1 35 1036 Patient First Name R 04 AN 1 25 1037 Patient Middle Name S 05 AN 1 25 1038 Name Prefix N 06 AN 1 10 1039 Patient Name Suffix S 07 AN 1 10 66 Identification Code Qualifier S 08 ID 1 2 34 HN II MI MR 67 Patient Identifier S 09 AN 2 80 706 Entity Relationship Code N 10 ID 2 2 98 Entity Identifier Code N 11 ID 2 3 Insured Name S 030 1 98 Entity Identifier Code R 01 ID 2 3 IL 1065 Entity Type Qualifier R 02 ID 1 1 1 2 1035 Subscriber Last Name S 03 AN 1 35 1036 Subscriber First Name S 04 AN 1 25 1037 Subscriber Middle Name S 05 AN 1 25 1038 Name Prefix N 06 AN 1 10 1039 Subscriber Name Suffix S 07 AN 1 10 66 Identification Code Qualifier R 08 ID 1 2 34 HN MI 67 Subscriber Identifier R 09 AN 2 80 706 Entity Relationship Code N 10 ID 2 2 98 Entity Identifier Code N 11 ID 2 3 Corrected Patient/Insured Name S 030 1 98 Entity Identifier Code R 01 ID 2 3 74 1065 Entity Type Qualifier R 02 ID 1 1 1 2 1035 Corrected Patient or Insured Last Name S 03 AN 1 35 1036 Corrected Patient or Insured First Name S 04 AN 1 25 1037 Corrected Patient or Insured Middle Name S 05 AN 1 25 1038 Name Prefix N 06 AN 1 10 1039 Corrected Patient or Insured Name Suffix S 07 AN 1 10 66 Identification Code Qualifier S 08 ID 1 2 C 67 Corrected Insured Identification Indicator S 09 AN 2 80 706 Entity Relationship Code N 10 ID 2 2 98 Entity Identifier Code N 11 ID 2 3 Service Provider Name S 030 1 98 Entity Identifier Code R 01 ID 2 3 82 1065 Entity Type Qualifier R 02 ID 1 1 1 2 1035 Rendering Provider Last or Organization Name S 03 AN 1 35 1036 Rendering Provider First Name S 04 AN 1 25 1037 Rendering Provider Middle Name S 05 AN 1 25 1038 Name Prefix N 06 AN 1 10 1039 Rendering Provider Name Suffix S 07 AN 1 10 66 Identification Code Qualifier R 08 ID 1 2 BD BS FI MC PC SL UP XX 67 Rendering Provider Identifier R 09 AN 2 80 706 Entity Relationship Code N 10 ID 2 2 98 Entity Identifier Code N 11 ID 2 3 Crossover Carrier Name S 030 1 98 Entity Identifier Code R 01 ID 2 3 TT 1065 Entity Type Qualifier R 02 ID 1 1 2 1035 Coordination of Benefits Carrier Name R 03 AN 1 35 1036 Name First N 04 AN 1 25 1037 Name Middle N 05 AN 1 25 1038 Name Prefix N 06 AN 1 10 1039 Name Suffix N 07 AN 1 10 66 Identification Code Qualifier R 08 ID 1 2 AD FI NI PI PP XV 67 Coordination of Benefits Carrier Identifier R 09 AN 2 80 706 Entity Relationship Code N 10 ID 2 2 98 Entity Identifier Code N 11 ID 2 3 Corrected Priority Payer Name S 030 2 98 Entity Identifier Code R 01 ID 2 3 PR 1065 Entity Type Qualifier R 02 ID 1 1 2 1035 Corrected Priority Payer Name R 03 AN 1 35 1036 Name First N 04 AN 1 25 1037 Name Middle N 05 AN 1 25 1038 Name Prefix N 06 AN 1 10 1039 Name Suffix N 07 AN 1 10 66 Identification Code Qualifier R 08 ID 1 2 AD FI NI PI PP XV 67 Corrected Priority Payer Identification Number R 09 AN 2 80 706 Entity Relationship Code N 10 ID 2 2 98 Entity Identifier Code N 11 ID 2 3 Inpatient Adjudication Information S 033 1 380 Covered Days or Visits Count R 01 R 1 15 380 PPS Operating Outlier Amount S 02 R 1 15 380 Lifetime Psychiatric Days Count S 03 R 1 15 782 Claim DRG Amount S 04 R 1 18 127 Remark Code S 05 AN 1 30 782 Claim Disproportionate Share Amount S 06 R 1 18 782 Claim MSP Pass-through Amount S 07 R 1 18 782 Claim PPS Capital Amount S 08 R 1 18 782 PPS-Capital FSP DRG Amount S 09 R 1 18 782 PPS-Capital HSP DRG Amount S 10 R 1 18 782 PPS-Capital DSH DRG Amount S 11 R 1 18 782 Old Capital Amount S 12 R 1 18 782 PPS-Capital IME Amount S 13 R 1 18 782 PPS-Operating Hospital Specific DRG Amount S 14 R 1 18 380 Cost Report Day Count S 15 R 1 15 782 PPS-Operating Federal Specific DRG Amount S 16 R 1 18 782 Claim PPS Capital Outlier Amount S 17 R 1 18 782 Claim Indirect Teaching Amount S 18 R 1 18 782 Nonpayable Professional Component Amount S 19 R 1 18 127 Remark Code S 20 AN 1 30 127 Remark Code S 21 AN 1 30 127 Remark Code S 22 AN 1 30 127 Remark Code S 23 AN 1 30 782 PPS-Capital Exception Amount S 24 R 1 18 Outpatient Adjudication Information S 035 1 954 Reimbursement Rate S 01 R 1 10 782 Claim HCPCS Payable Amount S 02 R 1 18 127 Remark Code S 03 AN 1 30 127 Remark Code S 04 AN 1 30 127 Remark Code S 05 AN 1 30 127 Remark Code S 06 AN 1 30 127 Remark Code S 07 AN 1 30 782 Claim ESRD Payment Amount S 08 R 1 18 782 Nonpayable Professional Component Amount S 09 R 1 18 Other Claim Related Identification S 040 5 128 Reference Identification Qualifier R 01 ID 2 3 1L 1W 9A 9C A6 BB CE EA F8 G1 G3 IG SY 127 Other Claim Related Identifier R 02 AN 1 30 352 Description N 03 AN 1 80 C040 Reference Identifier N 04 Rendering Provider Identification S 040 10 128 Reference Identification Qualifier R 01 ID 2 3 1A 1B 1C 1D 1G 1H D3 G2 127 Rendering Provider Secondary Identifier R 02 AN 1 30 352 Description N 03 AN 1 80 C040 Reference Identifier N 04 Claim Date S 050 4 374 Date Time Qualifier R 01 ID 3 3 036 050 232 233 373 Claim Date R 02 DT 8 8 337 Time N 03 TM 4 8 623 Time Code N 04 ID 2 2 1250 Date Time Period Format Qualifier N 05 ID 2 3 1251 Date Time Period N 06 AN 1 35 Claim Contact Information S 060 3 366 Contact Function Code R 01 ID 2 2 CX 93 Claim Contact Name S 02 AN 1 60 365 Communication Number Qualifier S 03 ID 2 2 EM FX TE 364 Claim Contact Communications Number S 04 AN 1 80 365 Communication Number Qualifier S 05 ID 2 2 EM EX FX TE 364 Claim Contact Communications Number S 06 AN 1 80 365 Communication Number Qualifier S 07 ID 2 2 EX 364 Communication Number Extension S 08 AN 1 80 443 Contact Inquiry Reference N 09 AN 1 20 Claim Supplemental Information S 062 14 522 Amount Qualifier Code R 01 ID 1 3 I T AU D8 DY F5 NL T2 ZK ZL ZM ZN ZO ZZ 782 Claim Supplemental Information Amount R 02 R 1 18 478 Credit/Debit Flag Code N 03 ID 1 1 Claim Supplemental Information Quantity S 064 15 673 Quantity Qualifier R 01 ID 2 2 CA CD LA LE NA NE NR OU PS VS ZK ZL ZM ZN ZO 380 Claim Supplemental Information Quantity R 02 R 1 15 C001 Composite Unit of Measure N 03 61 Free-Form Message N 04 AN 1 30 Service Payment Information S 070 999 Service Payment Information R 070 1 C003 Composite Medical Procedure Identifier R 01 235 Product or Service ID Qualifier R 01 ID 2 2 AD ER HC ID IV N4 NU RB ZZ 234 Procedure Code R 02 AN 1 48 1339 Procedure Modifier S 03 AN 2 2 1339 Procedure Modifier S 04 AN 2 2 1339 Procedure Modifier S 05 AN 2 2 1339 Procedure Modifier S 06 AN 2 2 352 Procedure Code Description S 07 AN 1 80 782 Line Item Charge Amount R 02 R 1 18 782 Line Item Provider Payment Amount R 03 R 1 18 234 National Uniform Billing Committee Revenue Code S 04 AN 1 48 380 Units of Service Paid Count S 05 R 1 15 C003 Composite Medical Procedure Identifier S 06 235 Product or Service ID Qualifier R 01 ID 2 2 AD ER HC ID IV N4 NU RB ZZ 234 Procedure Code R 02 AN 1 48 1339 Procedure Modifier S 03 AN 2 2 1339 Procedure Modifier S 04 AN 2 2 1339 Procedure Modifier S 05 AN 2 2 1339 Procedure Modifier S 06 AN 2 2 352 Procedure Code Description S 07 AN 1 80 380 Original Units of Service Count S 07 R 1 15 Service Date S 080 3 374 Date Time Qualifier R 01 ID 3 3 150 151 472 373 Service Date R 02 DT 8 8 337 Time N 03 TM 4 8 623 Time Code N 04 ID 2 2 1250 Date Time Period Format Qualifier N 05 ID 2 3 1251 Date Time Period N 06 AN 1 35 Service Adjustment S 090 99 1033 Claim Adjustment Group Code R 01 ID 1 2 CO CR OA PI PR 1034 Adjustment Reason Code R 02 ID 1 5 782 Adjustment Amount R 03 R 1 18 380 Adjustment Quantity S 04 R 1 15 1034 Adjustment Reason Code S 05 ID 1 5 782 Adjustment Amount S 06 R 1 18 380 Adjustment Quantity S 07 R 1 15 1034 Adjustment Reason Code S 08 ID 1 5 782 Adjustment Amount S 09 R 1 18 380 Adjustment Quantity S 10 R 1 15 1034 Adjustment Reason Code S 11 ID 1 5 782 Adjustment Amount S 12 R 1 18 380 Adjustment Quantity S 13 R 1 15 1034 Adjustment Reason Code S 14 ID 1 5 782 Adjustment Amount S 15 R 1 18 380 Adjustment Quantity S 16 R 1 15 1034 Adjustment Reason Code S 17 ID 1 5 782 Adjustment Amount S 18 R 1 18 380 Adjustment Quantity S 19 R 1 15 Service Identification S 100 7 128 Reference Identification Qualifier R 01 ID 2 3 1S 6R BB E9 G1 G3 LU RB 127 Provider Identifier R 02 AN 1 30 352 Description N 03 AN 1 80 C040 Reference Identifier N 04 Rendering Provider Information S 100 10 128 Reference Identification Qualifier R 01 ID 2 3 1A 1B 1C 1D 1G 1H 1J HPI SY TJ 127 Rendering Provider Identifier R 02 AN 1 30 352 Description N 03 AN 1 80 C040 Reference Identifier N 04 Service Supplemental Amount S 110 12 522 Amount Qualifier Code R 01 ID 1 3 B6 DY KH NE T T2 ZK ZL ZM ZN ZO 782 Service Supplemental Amount R 02 R 1 18 478 Credit/Debit Flag Code N 03 ID 1 1 Service Supplemental Quantity S 120 6 673 Quantity Qualifier R 01 ID 2 2 NE ZK ZL ZM ZN ZO 380 Service Supplemental Quantity Count R 02 R 1 15 C001 Composite Unit of Measure N 03 61 Free-Form Message N 04 AN 1 30 Health Care Remark Codes S 130 99 1270 Code List Qualifier Code R 01 ID 1 3 HE RX 1271 Remark Code R 02 AN 1 30 Table 3 - Footer S 030 1 Provider Adjustment S 010 >1 127 Provider Identifier R 01 AN 1 30 373 Fiscal Period Date R 02 DT 8 8 C042 Adjustment Identifier R 03 426 Adjustment Reason Code R 01 ID 2 2 127 Provider Adjustment Identifier S 02 AN 1 30 782 Provider Adjustment Amount R 04 R 1 18 C042 Adjustment Identifier S 05 426 Adjustment Reason Code R 01 ID 2 2 127 Provider Adjustment Identifier S 02 AN 1 30 782 Provider Adjustment Amount S 06 R 1 18 C042 Adjustment Identifier S 07 426 Adjustment Reason Code R 01 ID 2 2 127 Provider Adjustment Identifier S 02 AN 1 30 782 Provider Adjustment Amount S 08 R 1 18 C042 Adjustment Identifier S 09 426 Adjustment Reason Code R 01 ID 2 2 127 Provider Adjustment Identifier S 02 AN 1 30 782 Provider Adjustment Amount S 10 R 1 18 C042 Adjustment Identifier S 11 426 Adjustment Reason Code R 01 ID 2 2 127 Provider Adjustment Identifier S 02 AN 1 30 782 Provider Adjustment Amount S 12 R 1 18 C042 Adjustment Identifier S 13 426 Adjustment Reason Code R 01 ID 2 2 127 Provider Adjustment Identifier S 02 AN 1 30 782 Provider Adjustment Amount S 14 R 1 18 Transaction Set Trailer R 050 1 96 Transaction Segment Count R 01 N0 1 10 329 Transaction Set Control Number R 02 AN 4 9 Functional Group Trailer R 030 1 97 Number of Transaction Sets Included R 01 N0 1 6 28 Group Control Number R 02 N0 1 9 Interchange Achnowledgement S 020 I12 Interchange Control Number R 01 N0 9 9 I08 Interchange Date R 02 DT 6 6 I09 Interchange Time R 03 TM 4 4 I17 Interchange Achnowledgement Code R 04 ID 1 1 A E R I18 Interchange Note Code R 05 ID 3 3 000 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 018 019 020 021 022 023 024 025 026 027 028 029 030 031 Interchange Control Trailer R 030 1 I16 Number of Included Functional Groups R 01 N0 1 5 I12 Interchange Control Number R 02 N0 9 9