Pennsylvania
PROMISe
Companion Guide
™
Version 5010
835 Remittance Advice
September 2010, Version 1
™
Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
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September 2010
™
Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Table
of
Contents
Overview ......................................................................................................................................1
Companion Guide Instructions .................................................................................................2
Revisions to the Companion Guide ..........................................................................................3
Pennsylvania-Specific HIPAA Data Elements ..........................................................................5
Appendix A – Insurance Carriers ............................................................................................24
September 2010
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Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Overview
The Pennsylvania Department of Public Welfare's HIPAA-compliant Provider Reimbursement
and Operations Management Information System (PROMISe™) has adopted the new version
5010 X12 standards. These standards are in compliance with the CMS mandate
effective January 1, 2012.
This Companion Guide contains detailed instructions for interpreting 835 Remittance Advice
transaction records from PROMISe™. Please disregard any instructions that do not pertain
to the services for which you are submitting.
September 2010
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Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Companion
Guide
Instructions
One of the new terms born out of HIPAA is payer variability. As each payer works to make its
system HIPAA ready, there is a realization and an allowance that payers require information
and values/formats specific to their systems. As such, each payer requires that transactions be
completed with specific data. This Companion Guide was developed to communicate the
Pennsylvania Medical Assistance-specific information required to successfully interpret the 835
transaction.
This Companion Guide is to be used in conjunction with the CMS HIPAA Implementation Guide
found at http://www.wpc-edi.com. The CMS HIPAA Implementation Guide takes precedence
and is the main source of information about the transaction sets. The Companion Guide
contains:
•
DPW’s interpretation/application of the data elements that support Medical Assistance
transaction submissions.
•
The methods utilized to convey data that are not included in the CMS HIPAA
Implementation Guide, but are required for processing Pennsylvania Department of
Public Welfare transactions.
•
Clarification for certain, less obvious, but still standard, uses of the transaction (i.e.,
claim adjustment reason codes, and elements to hold previous payer coinsurance, copay, and deductible).
September 2010
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Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Revisions to the
Companion Guide
To aid the provider community in organizing these Companion Guides and the revisions that
may occur, we have developed a revision schedule and notification process.
The initial release of this companion guide was September 2010. The first release reflected all
the known information as of that date. However, as the implementation phases of PROMISe™
progress, updates and releases of new information may be forthcoming.
Revision Process:
For each new release of this Companion Guide, the information that has been changed since
the previous version will be located in that specific section of the guide. If a revision is made to a
data element, it will be detailed in the Revision(s) Description section in the table containing the
element. DPW will clearly define the change that was made so it can be integrated into your
process.
Updated releases of the Transaction Guide will be posted on the DPW website. You are
encouraged to check this site regularly.
Revision(s)
Description
September 2010
9/1/2010 – Original 5010 Version
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Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
PennsylvaniaSpecific HIPAA
Data Elements
Page #
C.3
Field Name
5010 values,
Functions
Description of 5010 Change
PROMISe™
Specific
Instructions
ISA01: Authorization
Information Qualifier
“00”
ISA02: Authorization
Information
Spaces
ISA03: Security
Information Qualifier
“00”
ISA04: Security
Information
Spaces
ISA05: Interchange ID
Qualifier
“30”
ISA06: Interchange
Sender ID
"345529167"
Production
"445314156"
Model Office
ISA07: Interchange ID
Qualifier
ISA08: Interchange
Receiver ID
ISA09: Interchange Date
ISA10: Interchange Time
ISA11: Interchange
Control Standards
Identifier
"^"
Changed from a constant U to a
character representing repeated data
within a data element
"^"
ISA12: Interchange
Control Version Number
"00501"
Changed value to represent 5010
"00501"
ISA13: Interchange
Control Number
ISA14:
Acknowledgement
Requested
September 2010
“0”
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Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Page #
Field Name
5010 values,
Functions
Description of 5010 Change
PROMISe™
Specific
Instructions
ISA15: Usage Indicator
ISA16: Component
Element Separator
C.7
GS01: Functional
Identifier Code
“:”
"HP"
GS02: Application
Sender’s Code
"345529167"
Production
"445314156"
Model Office
GS03: Application
Receiver’s Code
GS04: Date
GS05: Time
GS06: Group Control
Number
68
“0001”
GS07: Responsible
Agency Code
"X"
GS08:
Version/Release/Industry
Identifier Code
"005010X221"
ST01: Transaction Set
Identifier Code
"835"
“X”
Changed standard ID for 5010
"005010X221"
ST02: Transaction Set
Control Number
69
BPR01: Transaction
Handling Code
BPR02: Total Actual
Provider Payment
Amount
BPR03: Credit/Debit
Flag Code
“C”
BPR04: Payment Method
Code
BPR05: Payment Format
Code
BPR06: DFI Number
Qualifier Code
BPR07: DFI
Identification Number
September 2010
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Page #
Field Name
5010 values,
Functions
Description of 5010 Change
PROMISe™
Specific
Instructions
BPR08: Account Number
Qualifier Code
BPR09: Account Number
BPR10: Payer Identifier
BPR11: Originating
Company Supplemental
Code
BPR12: DFI Number
Qualifier Code
BPR13: Provider Bank
ID Number
BPR14: Account Number
Qualifier Code
BPR15: Account Number
BPR16: Check Issue or
EFT Effective Date
BPR17: Business
Function Code
BPR18: DFI Number
Qualifier
BPR19: DFI
Identification Number
BPR20: Account Number
Qualifier
BPR21: Account Number
77
TRN01: Trace Type
Code
“1”
TRN02: Check or EFT
Trace Number
TRN03: Payer Identifier
TRN04: Originating
Company Supplemental
Code
79
CUR FOREIGN
CURRENCY
INFORMATION
September 2010
PROMISe™ does
not use this
segment
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Page #
82
Field Name
5010 values,
Functions
Description of 5010 Change
PROMISe™
Specific
Instructions
REF01: Reference
Identification Qualifier
Code
REF02: Receiver
Identification
84
85
REF VERSION
IDENTIFICATION
DTM01: Date Time
Qualifier
PROMISe™ does
not use this
segment
"405"
DTM02: Production Date
LOOP 1000A: PAYER
IDENTIFICATION
87
N101: Entity Identifier
Code
“PR”
N102: Name
N103: Identification
Code Qualifier
"XV"
N104: Identification
Code
"236003113"
N301: Payer Address
"OFFICE OF
MEDICAL
ASSISTANCE
PROGRAMS"
N302: Payer Address
"SUPPORT
SERVICES
SECTION /
ENROLLMENT
PO BOX 69022"
N401: Payer City Name
"HARRISBURG"
N402: Payer State Code
"PA"
N403: Postal Code
"171069022"
89
90
"DEPARTMENT
OF PUBLIC
WELFARE"
N404: Country Code
92
REF ADDITIONAL
PAYER
IDENTIFICATION
September 2010
PROMISe™ does
not use this
segment
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Page #
Field Name
94
PER01: Contact Function
Code
5010 values,
Functions
Description of 5010 Change
PROMISe™
Specific
Instructions
“CX” if sent
PER02: Payer Contact
Name
PER03: Communication
Number Qualifier
“TE” if sent
PER04: Payer Contact
Communication Number
PER05: Communication
Number Qualifier
“TE” if sent
PER06: Payer Contact
Communication Number
PER07: Communication
Number Qualifier
PER08: Payer Contact
Communication Number
PER09: Contact Inquiry
Reference
97
PER01: Contact Function
Code
"BL"
PER02: Payer Contact
Name
PER03: Communications
Number Qualifier
"EM", "TE",
"UR"
PER04: Payer Contact
Communication Number
PER05: Communications
Number Qualifier 2
PER06: Payer Contact
Communication Number
"EM", "EX",
"FX", "TE",
"UR"
New Required Segment
New Required Segment
"PROVIDER
ASSISTANCE
CENTER (PAC)”
New Required Segment
"TE"
New Required Segment
"800-248-2152"
"EM"
"promise835techn
icalcontact@hp.co
m" Note:
Questions/inquiries
sent to this mailbox,
for any matter other
than the technical
aspects of the 835,
cannot be
guaranteed a
response.
September 2010
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Page #
Field Name
PER07: Communications
Number Qualifier 3
5010 values,
Functions
Description of 5010 Change
"EM", "EX",
"FX", "TE",
"UR"
PROMISe™
Specific
Instructions
PROMISe™ will
not send this data
element
PER08: Payer Contact
Communications Number
PROMISe™ will
not send this data
element
PER09: Contact Inquiry
Reference
PROMISe™ will
not send this data
element
PER PAYER WEB SITE
New Segment
PROMISe™ will
not use this
segment
Added Code XV for CMS Plan ID.
“XX” if payee
has an NPI
"FI" if payee does
not have an NPI
100
LOOP 1000B: PAYEE
IDENTIFICATION
102
N101: Entity Identifier
Code
"PE"
N102: Name
N103: Identification
Code Qualifier
"FI", "XV",
"XX"
N104: Identification
Code
N105: Entity
Relationship Code
N106: Entity Identifier
Code
104
N301: Payee Address
Line
N302: Payee Address
Line 2
105
N401: Payee City Name
N402: Payee State Code
N403 : Payee Postal Zone
or Zip Code
N404: Country Code
N405: Location Qualifier
N406: Location Identifier
September 2010
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Page #
107
Field Name
REF01: Reference
Identification Qualifier
5010 values,
Functions
Description of 5010 Change
"0B", "D3",
"PQ", "TJ"
"PQ" if sent
REF02: Additional Payee
Identifier
107
109
REF01: Reference
Identification Qualifier
PROMISe™
Specific
Instructions
This will be the
provider's Legacy
(MAID)
"0B", "D3",
"PQ", "TJ"
Changed list of qualifiers. Note
that 1D for Medicaid was always
discouraged and now is not valid
"TJ" if sent
REF02: Additional Payee
Identifier
This will be the
provider's Tax ID
RDM REMITTANCE
DELIVERY METHOD
PROMISe™ will
not send this
segment
LOOP 2000: HEADER
NUMBER
111
LX01: Assigned Number
112
TS3: PROVIDER
SUMMARY
INFORMATION
PROMISe™ will
not send this
segment
117
TS2: PROVIDER
SUPPLEMENTAL
SUMMARY
INFORMATION
PROMISe™ will
not send this
segment
LOOP 2100: CLAIM
PAYMENT
INFORMATION
CLP01: Patient Control
Number
123
September 2010
Patient Account
Number from
Loop 2300,
CLM01 if the
claim was
submitted as an
837.
Prescription
Number if the
claim was
submitted as an
NCPDP or 837P
to Drug
Otherwise it will
be "0"
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Page #
Field Name
5010 values,
Functions
Description of 5010 Change
CLP02: Claim Status
Code
PROMISe™
Specific
Instructions
PROMISe™ will
send "1" for paid
as primary, "2"
for paid as
secondary, "3" for
paid as tertiary,
"4" for denied
(any denial), "22"
for void/reversal.
CLP03: Total Claim
Charge Amount
CLP04: Claim Payment
Amount
CLP05: Patient
Responsibility Amount
Use this
monetary
amount for the
payer’s
statement of the
patient
responsibility
amount for this
claim, which
can include such
items as
deductible, noncovered
services, co-pay
and coinsurance. This
is not used for
reversals.
Usage Note changed
CLP06: Claim Filing
Indicator Code
“MC”
CLP07: Payer Claim
Control Number
This will be the
Internal Control
Number (ICN)
assigned to the
claim by
PROMISe™ and
is the value to use
for all
correspondence,
corrections, or
voids of the claim.
September 2010
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Page #
Field Name
5010 values,
Functions
Description of 5010 Change
PROMISe™
Specific
Instructions
CLP08: Facility Code
Value
CLP09: Claim Frequency
Type Code
CLP10: Patient Status
Code
CLP11: Diagnosis Relate
Group Code
CLP12: Diagnosis
Related Group Weight
CLP13: Discharge
Fraction
CAS01: Claim
Adjustment Group Code
"CO", "OA",
"PI", "PR"
Removed claim adjustment group
code CR for corrections and
reversals. See page 30 for how this
change is to be handled.
CAS02: Claim
Adjustment Reason Code
Required to
report a nonzero adjustment
applied at the
service level for
the claim
adjustment
group code
reported in
CAS01.
Added usage note
129
CAS03: Adjustment
Amount
CAS04: Adjustment
Quantity
CAS05: Claim
Adjustment Reason Code
CAS06: Adjustment
Amount
CAS07: Adjustment
Quantity
CAS08: Claim
Adjustment Reason Code
CAS09: Adjustment
Amount
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Page #
Field Name
5010 values,
Functions
Description of 5010 Change
PROMISe™
Specific
Instructions
CAS10: Adjustment
Quantity
CAS11: Claim
Adjustment Reason Code
CAS12: Adjustment
Amount
CAS13: Adjustment
Quantity
CAS14: Claim
Adjustment Reason Code
CAS15: Adjustment
Amount
CAS16: Adjustment
Quantity
CAS17: Claim
Adjustment Reason Code
CAS18: Adjustment
Amount
CAS19: Adjustment
Quantity
137
NM101: Entity Identifier
Code
“QC”
NM102: Entity Type
Qualifier
“1”
NM103: Patient Last
Name
NM104: Patient First
Name
NM105: Patient Middle
Name
NM107: Name Suffix
NM108: Identification
Code Qualifier
“MR”
NM109: Patient Identifier
This value will be
the PROMISe™
Recipient ID
(RID)
September 2010
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Page #
Field Name
5010 values,
Functions
Description of 5010 Change
PROMISe™
Specific
Instructions
NM1: INSURED' NAME
PROMISe™ will
not send this
segment
143
NM1: CORRECTED
PATIENT/INSURED
NAME
PROMISe™ will
not send this
segment
146
NM101: Entity Identifier
Code
“82”, if sent
NM102: Entity Type
Qualifier
“1” if sent
140
NM103: Rendering
Provider Last Name or
Organization
NM104: Rendering
Provider First Name
NM105: Rendering
Provider Middle Name
NM107: Name Suffix
NM108: Identification
Code Qualifier
"BD", "BS",
"FI", "MC",
"PC", "SL",
"UP", "XX"
Notes changed on FI and XX
"XX" if
Rendering
Provider is sent
and has an NPI
“MC” if
Rendering
Provider is sent
and does not have
an NPI
NM109: Rendering
Provider Identifier
150
153
NM1: CROSSOVER
CARRIER NAME
PROMISe™ will
not send this
segment
NM101: Entity Identifier
Code
“PR” if sent
NM102: Entity Type
Qualifier
“2” if sent
NM103: Corrected
Priority Payer Name
NM108: Identification
Code Qualifier
September 2010
"AD", "FI",
"NI", "PI", "PP",
"XV"
“PI” if sent
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Page #
156
159
Field Name
5010 values,
Functions
Description of 5010 Change
PROMISe™
Specific
Instructions
NM109: Corrected
Priority Payer Identifier
Number
This value will be
the PROMISe™
identifier for the
other payer.
Refer to
Appendix A
NM1: OTHER
SUBSCRIBER NAME
PROMISe™ will
not send this
segment
MIA01: Covered Days or
Visit Count
"0" if segment
created
MIA02: PPS Operating
Outlier Amount
Required when
an additional
payment is made
for excessive
cost incurred by
the provider
when the payer
is Medicare or
Medicaid and
the value is
different than
zero. If not
required by this
implementation
guide, do not
send.
Usage Note Changed
PROMISe™ will
not send a value
in this data
element
MIA03: Lifetime
Psychiatric Days Count
PROMISe™ will
not send a value
in this data
element
MIA04: Claim DRG
Amount
PROMISe™ will
not send a value
in this data
element
MIA05: Remark Code
MIA06: Claim
Disproportionate Share
Amount
PROMISe™ will
not send a value
in this data
element
MIA07: Claim MSP
Pass-through Amount
PROMISe™ will
not send a value
in this data
element
September 2010
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Page #
Field Name
5010 values,
Functions
Description of 5010 Change
PROMISe™
Specific
Instructions
MIA08: Claim PPS
Capital Amount
PROMISe™ will
not send a value
in this data
element
MIA09: PPS-Capital FSP
DRG Amount
PROMISe™ will
not send a value
in this data
element
MIA10: PPS-Capital
HSP DRG Amount
PROMISe™ will
not send a value
in this data
element
MIA11: PPS-Capital
DSH DRG Amount
PROMISe™ will
not send a value
in this data
element
MIA12: Old Capital
Amount
PROMISe™ will
not send a value
in this data
element
MIA13: PPS-Capital
IME Amount
PROMISe™ will
not send a value
in this data
element
MIA14: PPS-Operating
Hospital Specific DRG
Amount
PROMISe™ will
not send a value
in this data
element
MIA15: Cost Report Day
Count
PROMISe™ will
not send a value
in this data
element
MIA16: PPS-Operating
Federal Specific DRG
Amount
PROMISe™ will
not send a value
in this data
element
MIA17: Claim PPS
Capital Outlier Amount
PROMISe™ will
not send a value
in this data
element
September 2010
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Page #
Field Name
5010 values,
Functions
Description of 5010 Change
PROMISe™
Specific
Instructions
MIA18: Claim Indirect
Teaching Amount
PROMISe™ will
not send a value
in this data
element
MIA19: Nonpayable
Professional Component
Amount
PROMISe™ will
not send a value
in this data
element
MIA20: Remark Code
MIA21: Remark Code
MIA22: Remark Code
166
MOA01: Reimbursement
Rate
MOA02: Claim HCPCS
Payable Amount
PROMISe™ will
not send a value
in this data
element
Required when
the outpatient
institutional
claim HCPCS
Payable Amount
is not zero for a
Medicare or
Medicaid claim.
If not required
by this
implementation
guide, do not
send.
Usage Note Changed
MOA03: Remark Code
MOA04: Remark Code
MOA05: Remark Code
MOA06: Remark Code
MOA07: Remark Code
MOA08: Claim ESRD
Payment Amount
PROMISe™ will
not send a value
in this data
element
MOA09: Nonpayable
Professional Component
Amount
PROMISe™ will
not send a value
in this data
element
September 2010
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Page #
169
Field Name
5010 values,
Functions
Description of 5010 Change
PROMISe™
Specific
Instructions
REF01: Reference
Identification Qualifier
REF02: Other Claim
Related Identifier Medical Record Number
169
REF01: Reference
Identification Qualifier
REF02: Other Claim
Related Identifier - Social
Security Number
REF01: Reference
Identification Qualifier
171
"0B", "1A",
"1B", "1C",
"1D", "1G",
"1H", "1J",
"D3", "G2",
"LU"
Added qualifiers 0B, 1J, and LU
REF02: Rendering
Provider Identification
173
DTM01: Date/Time
Qualifier
"232"
DTM02: Claim Date First Date of Service
173
DTM01: Date/Time
Qualifier
"233"
DTM02: Claim Date Last Date of Service
175
DTM01: Date/Time
Qualifier
"036"
Expiration
New Segment
DTM02: Claim Date Coverage Expiration
Date
177
DTM CLAIM
RECEIVED DATE
PROMISe™ will
not use this
segment
179
PER CLAIM CONTACT
INFORMATION
PROMISe™ will
not use this
segment
182
AMT01: Amount
Qualifier Code
September 2010
Usage Note change
"AU" if sent
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Page #
Field Name
5010 values,
Functions
Description of 5010 Change
PROMISe™
Specific
Instructions
AMT02: CLAIM
SUPPLEMENTAL
INFORMATION
AMOUNT
QTY01: Quantity
Qualifier Code
"CA"- Covered
Days
"NE" - NonCovered Days
"CD" Coinsurance Days
184
QTY02: Claim
Supplemental
Information Quantity
LOOP 2110: SERVICE
PAYMENT
INFORMATION
186
SVC01-1:
Product/Service ID
Qualifier
See page 187
SVC01-2: Procedure
Code
SVC01-3: Procedure
Modifier
SVC01-4: Procedure
Modifier
SVC01-5: Procedure
Modifier
SVC01-6: Procedure
Modifier
SVC01-7: Description
SVC02: Line Item
Charge Amount
SVC03: Line Item
Provider Payment
Amount
SVC04: NUBC Revenue
Code
September 2010
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Page #
Field Name
5010 values,
Functions
SVC05: Units of Service
Paid Count
Required when
the paid units of
service are
different than
one. If not
required by this
implementation
guide, may be
provided at
sender’s
discretion, but
cannot be
required by the
receiver.
SVC06-1:
Product/Service ID
Qualifier
See page 191
Description of 5010 Change
PROMISe™
Specific
Instructions
SVC06-2: Procedure
Code
SVC06-3: Procedure
Modifier
SVC06-4: Procedure
Modifier
SVC06-5: Procedure
Modifier
SVC06-6: Procedure
Modifier
SVC06-7: Description
SVC07: Original Units of
Service Count
194
DTM01: Date/Time
Qualifier
"150", "151",
"472"
DTM02: Claim Date
CAS01: Claim
Adjustment Group Code
196
CAS02: Claim
Adjustment Reason Code
"CO", "OA",
"PI", "PR"
Removed claim adjustment group
code CR for corrections and
reversals. See TR3 page 30 for how
this change is to be handled.
Added usage note
CAS03: Adjustment
Amount
September 2010
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Page #
Field Name
5010 values,
Functions
Description of 5010 Change
PROMISe™
Specific
Instructions
CAS04: Adjustment
Quantity
CAS05: Claim
Adjustment Reason Code
CAS06: Adjustment
Amount
CAS07: Adjustment
Quantity
CAS08: Claim
Adjustment Reason Code
CAS09: Adjustment
Amount
CAS10: Adjustment
Quantity
CAS11: Claim
Adjustment Reason Code
CAS12: Adjustment
Amount
CAS13: Adjustment
Quantity
CAS14: Claim
Adjustment Reason Code
CAS15: Adjustment
Amount
CAS16: Adjustment
Quantity
CAS17: Claim
Adjustment Reason Code
CAS18: Adjustment
Amount
CAS19: Adjustment
Quantity
204
REF01: Reference
Identification Qualifier
Code
"1S", "APC",
"BB", "E9",
"G1", "G3",
"LU", "RB"
REF02: Service
Identification - Service
Payment Identification
September 2010
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Page #
206
Field Name
REF01: Reference
Identification Qualifier
Code
5010 values,
Functions
Description of 5010 Change
"6R"
New Separate REF segment for
Provider Control Number
"0B", "1A",
"1B", "1C",
"1D", "1G",
"1H", "1J",
"D3", "G2",
"HPI", "SY",
"TJ"
Changed valid qualifier list
PROMISe™
Specific
Instructions
REF02 Service
Identification - Line Item
Control Number
REF01: Reference
Identification Qualifier
Code
207
REF02: Rendering
Provider Identifier
209
REF HEALTH CARE
POLICY
IDENTIFICATION
211
AMT01: Amount
Qualifier Code
PROMISe will
not send this
segment
Added clarification note to value
B6.
AMT02: Service
Supplemental Amount
213
QTY SERVICE
SUPPLEMENTAL
QUANTITY
215
LQ01 Code List Qualifier
Code
PROMISe™ will
not send this
segment
LQ02: Remark Code
PLB01: Provider
Identifier
217
When the
National
Provider
Identifier (NPI)
is mandated and
the provider is a
covered health
care provider
under that
mandate, this
must be the NPI
assigned to the
provider.
Changed to require the NPI if the
provider is a covered entity under
NPI.
PLB02: Fiscal Period
Date
September 2010
Page 23
™
Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Page #
Field Name
PLB03-1: Adjustment
Reason Code
5010 values,
Functions
See pages 219,
220 for codes
WU, AP, and
FB
Description of 5010 Change
PROMISe™
Specific
Instructions
"72" - Refund
Applied
"CT" - Capitation
Payment
"FB" Adjustment A/R
Setup
"IR" - IRS
Withholding
"LE" - Levy
Withholding
"WO" - Account
Receivable
"LS" - Non-Claim
Expenditures
PLB03-2: Provider
Adjustment Identifier
PLB04: Provider
Adjustment Amount
228
SE01: Number of
Included Segments
SE02: Transaction Set
Control Number
C.9
GE01: Number of
Transaction Sets Included
GE02: Group Control
Number
C.10
IEA01: Number of
Included Functional
Groups
IEA02: Interchange
Control Number
Appendix A – Insurance
Carriers
Insurance Listings with Addresses:
September 2010
Page 24
™
Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Carrier Code
Carrier Name
100
Medicare Part B
103
Medicare Part D
200
Independence Blue Cross
1901 Market Street
Philadelphia, PA. 19103
201
Highmark Blue Cross/Blue
Shield
Fifth Avenue Place
120 Fifth Ave/Suite P3105
Pittsburgh, PA. 15222
202
Capital Blue Cross
2500 Elmerton Avenue
Harrisburg, PA. 17177
203
Blue Cross of N.E. PA
19 N Main Street
Wilkes-Barre, PA. 18711
240
Security 65 Independence
Plan
1901 Market Street
Philadelphia, PA. 19103
241
Security 65 Highmark Plan
5th Avenue Place
Pittsburgh, PA. 15222
242
Security 65 Capital Plan
Dept 778995
Harrisburg, PA. 17177-8995
243
Security 65 Northeast Plan
70 N Main Street
Wilkes-Barre, PA. 18711
244
Highmark Service Company
5th Avenue Place
120 5th Avenue Place/Suite P3105
Pittsburgh, PA. 15222
249
Blue Cross Medigap (out-ofstate)
299
Blue Cross Out of State
300
PA Blue Shield
September 2010
Address
P.O. Box 898206
Camp Hill, PA. 17089-0400
Page 25
™
Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Carrier Code
Carrier Name
Address
300
PA Blue Shield
P.O. Box 890500
Camp Hill, PA. 17089-0500
300
PA Blue Shield
P.O. Box 890062
Camp Hill, PA. 17089-0062
302
Highmark Blue Shield
P.O. Box 898206
Camp Hill, PA. 17089-8206
302
Highmark Blue Shield
P.O. Box 890173
Camp Hill, PA. 17089-0173
302
Highmark Blue Shield
P.O. Box 890500
Camp Hill, PA. 17089-0500
340
Blue Shield Medigap - Security P.O. Box 898845
65
Camp Hill, PA. 17089-8845
349
Blue Shield Medigap (out-ofstate)
399
Blue Shield Out Of State
400
TRICARE/United Concordia
TDP Claims Processing/PO Box 69411
Harrisburg, PA 17106
400
TRICARE (formerly
CHAMPUS)
Palmetto GBA/PO Box 7011
Camden, SC 29020
400
TRICARE/Express Scripts
PO Box 390007
Bloomington, MN 55439
401
ChampVA
PO Box 65023
Denver, CO 80206-9023
401
ChampVA
PO Box 65023
Denver, CO 80206-9023
500
Personal Choice 65/Keystone
65
1901 Market Street
Philadelphia, PA 19103
September 2010
Page 26
™
Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Carrier Code
Carrier Name
Address
501
Freedom Blue
120 Fifth Ave, Suite P5501
Pittsburgh, PA 15222
502
Capital SeniorBlue
2500 Elmerton Ave
Harrisburg, PA 17177
503
Senior Partners Terminated
7/31/07 now 516
PO Box 5194
New York, NY 10004-5194
504
SecurityBlue
120 Fifth Ave, Suite P5501
Pittsburgh, PA 15222
505
Aetna
151 Farmington Avenue
Hartford, CT 06156
506
Gateway Health Plan Medicare 600 Grant Street, 41st Floor
Assured
Pittsburgh, PA 15219
507
Humana
101 East Main Street
Louisville, KY 40202
508
SecureHorizons
13621 NW 12th St, FL075-1000
Sunrise, FL 33323
509
Advantra
11 Stanwix Street, Suite 2300
Pittsburgh, PA 15222
510
Sterling Option 1
2219 Rimland Dr, PO Box 5348
Bellingham, WA 98226
511
Geisinger Health Plan
100 North Academy Avenue
Danville, PA 17822
512
Amerihealth 65
1901 Market Street
Philadelphia, PA 19103
513
Unison Advantage
1001 Brinton Road
Pittsburgh, PA 15221
514
Keystone 65 Complete
1901 Market Street
Philadelphia, PA 19103
September 2010
Page 27
™
Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Carrier Code
Carrier Name
Address
515
UPMC For Life
112 Washington Place
Pittsburgh, PA 15219
516
Bravo Health Pennsylvania
3601 O’Donnell Street
Baltimore, MD 21224
517
Today’s Options
4888 Loop Central Dr,
Suite 900
Houston, TX 77081
518
United Healthcare (Evercare)
13621 NW 12th Street
Sunrise, FL 33323
519
Keystone SeniorBlue
2500 Elmerton Avenue
Harrisburg, PA 17177
520
WellCare
8735 Henderson Road
Tampa, FL 33634
521
Horizon Blue Cross Blue
Shield of New Jersey
3 Penn Plaza East
Newark, NJ 07105
522
Healthfirst Medicare Plan
25 Broadway, 9th Floor
New York, NY 10004
523
Trustees of the University of
Pennsylvania
4508 Chestnut Street
Philadelphia, PA 19139
524
Community LIFE
2400 Ardmore Blvd, Suite 700
Pittsburgh, PA 15221
525
LIFE Pittsburgh
875 Greentree Road
One Parkway Ctr, Suite 200
Pittsburgh, PA 15220
526
St Agnes LIFE
1900 South Broad Street
Philadelphia, PA 19145
527
Coventry Healthcare
3721 Tecport Drive
Harrisburg, PA 17106
September 2010
Page 28
™
Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Carrier Code
Carrier Name
Address
528
Universal Health Care
150 2nd Ave North, Suite 400
Saint Petersburg, FL 33701
529
Citrus Health Care
5420 Bay Center Dr, Suite 250
Tampa, FL 33609
530
GHI Medicare Choice
441 Ninth Avenue
New York, NY 10001
531
UniCare
PO Box 9154
Oxnard, CA 93031
532
Anthem Blue Cross/Blue
Shield
4241 Irwin Simpson Road, OHO205A037
Mason, OH 45040
533
Care Improvement Plus
250 West Pratt St, Suite 230
Baltimore, MD 21201
534
Life at Home
101 East State Street
Kennett Square, PA 19348
535
Senior LIFE Johnstown
209 Sigma Drive
Pittsburgh, PA 15238
536
USACare
259 Monroe Ave
Rochester, NY 14607
537
HIP Health Plan of Greater
New York
55 Water Street
New York, NY 10041-8190
538
MD MedicareChoice
5501 West Waters Ave, Ste 401
Tampa, FL 33634
539
HealthMarkets Care Assured
9151 Blvd 26
North Richland Hills, TX 76180
540
LIFE LUTHERAN
840 Fifth Avenue
Chambersburg, PA 17201
September 2010
Page 29
™
Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Carrier Code
Carrier Name
Address
541
LIFE Beaver County
1323 Freedom Road
Cranberry Twp, PA 16066
542
CIGNA Medicare Access
900 Cottage Grove Road, Hartford, CT
06152
543
Universal American
1001 Heathrow Park Lane, Suite 5001,
Lake Mary, FL 32746
598
Unlisted Medicare Advantage
HMO’s
600
Medicare Part A
700
Delta Dental of PA
One Delta Drive
Mechanicsburg, PA 17055
701
Amalgamated Life Insurance
Co.
730 Broadway
New York, NY. 10003-9511
702
Aetna Life Insurance Co.
151 Farmington Avenue
Hartford, CT. 06156
703
Allstate Insurance Co.
60 Allstate Plaza S.
Northbrook, IL. 60062
704
Bankers Life & Casualty Co.
222 Merchandise Mart Plaza
Chicago, IL. 60654
705
United Concordia
4401 Deer Path Road
Harrisburg, PA 17110
706
CONSECO
11825 N Pennsylvania St
Carmel, IN 46032
707
Combined Insurance Co. of
America
1000 Milwaukee Ave
Glenview, IL 60025
708
CIGNA
900 Cottage Road
Bloomfield, CT 06002
September 2010
Page 30
™
Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Carrier Code
Carrier Name
Address
709
Argus
PO Box 419019
Kansas City, MO 64141
710
Continental Casualty Insurance 333 South Wabash
Co.
Chicago, IL. 60604
711
American General
70 Pine Street
New York, NY 10270
712
Eastern Life & Health
Insurance Co.
25 Race Avenue
Lancaster, PA 17608
713
AXA Equitable Life Insurance PO Box 1047
Co.
Charlotte, NC 28201
714
Inter-Co. Hospital Plan
720 Blair Mill Road
Horsham, PA. 19044
715
Inter-Co. Phys. Service Plan
720 Blair Mill Road
Horsham, PA. 19044
716
John Hancock Mutual Life
Insurance Co.
P.O. Box 111
Boston, MA. 02117
718
Life Insurance Co. North
America
1601 Chestnut Street
Philadelphia, PA. 19192
719
Lincoln Financial Group
8801 Indian Hills Drive
Omaha, NE 68114
720
Mass Mutual Life Insurance
Co.
1295 State Street
Springfield, MA 01111
721
United Healthcare
P O Box 740800
Atlanta, GA 30374
722
Mutual of Omaha Insurance
Co.
Mutual Of Omaha Plaza
Omaha, NE. 68175
723
People Benefit Life Insurance
Co.
Claims Dept.
Valley Forge, PA. 19493
September 2010
Page 31
™
Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Carrier Code
Carrier Name
Address
724
New York Life Insurance Co.
51 Madison Avenue
New York, NY. 10010
725
Transamerica Occidental
Insurance Co.
P.O. Box 2101
Los Angeles, CA. 90051-2101
726
Phoenix Mutual Life Insurance PO Box 22012
Co.
Albany, NY 12201-2012
727
Provident Life/Accident
Insurance Co.
Fountain Square
Chattanooga, TN. 37402
728
Prudential Insurance Co. of
America
751 Broad Street
Newark, NJ 07102
730
Travelers Insurance
One Town Square MPB
Hartford, CT 06183
731
National Association of Letter
Carriers
20547 Waverly Court
Ashburn, VA 20149
732
Washington National Insurance PO Box 2004
Co.
Carmel, IN 46032-3004
733
Paid Prescription (MEDCO)
P.O. Box 6121
Fair Lawn, NJ. 07410-0999
734
American Postal Workers
Union
PO Box 967
Silver Spring, MD 20910
735
Accordia National
P.O. Box 3262
East Charleston, WV 25332
736
Employers Health Insurance
Co.
PO Box 14610
Lexington, KY 40512-4610
737
Jefferson-Pilot Life Insurance
Co.
P.O. Box 21008
Greensboro, NC. 27420
738
Philadelphia American Life
P.O. Box 4884
September 2010
Page 32
™
Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Carrier Code
Carrier Name
Address
Ins. Co.
Houston, TX. 77210
739
Protective Life Insurance Co.
2801 HWY 280 South
Birmingham, AL 35223
740
Commercial Medigap
741
AARP Medigap
742
National Vision Administrators P.O. Box 1981
East Hanover, NJ. 07936-0981
743
Express Scripts
P.O. Box 390007
Bloomington, MN 55439
744
PEBTF
150 S. 43rd Street, Suite 1
Harrisburg, PA. 17111-5700
745
National Pharmaceutical
Services
P.O. Box 407
Boystown, NE. 68010
746
Eagle Managed Care
Terminated 12/31/1999
30 Hunter Lane P.O. Box 7011
Camp Hill, PA. 17011
747
PCS
950 E. Shea Blvd.
Scottsdale, AZ. 85260
748
Merck MEDCO
1810 Lincoln Hwy
N Versailles, PA 15127
749
Caremark
PO Box 686005
San Antonio, TX 78268
750
Aetna HMO Health PLS
East/Central PA
PO Box 981107
El Paso, TX 79998-1107
751
Americhoice Personal Care
Plus Terminated 7/31/05
PO Box 16000
Phoenix, AZ 85011-6000
752
Alliance Health Network
1700 Peach Street
September 2010
PO Box 740819
Atlanta, GA 30374-0819
Page 33
™
Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Carrier Code
Carrier Name
Address
Erie, PA. 16501
753
Advantage Health Plan PA
121 Seventh Street
Pittsburgh, PA. 15222-3408
754
Cigna Healthcare of PA
P.O. Box 15422 STE CHP
Wilmington, DE. 19803
755
Geisinger Health Plan
PO Box 8200
Danville, PA 17821-8200
756
Unison Advantage (3 Rivers)
Terminated 6/30/06
Use code 513.
PO Box 1018
Monroeville, PA 15146
757
HealthAmerica /Health
Assurance
3721 Tecport Drive
PO Box 67103
Harrisburg, PA 17106
758
HealthAmerica /Health
Assurance
(Pittsburgh)
PO Box 7088
London, KY 40742
759
Healthguard of Lancaster
Terminated 2/1/2006
280 Granite Run Drive
Lancaster, PA. 17601
760
First Priority Health
19 N. Main Street
Wilkes-Barre, PA. 18711
761
Keystone Health Plan Central
P.O. Box 898812
Camp Hill, PA. 17089-8812
762
Keystone Health Plan East
1901 Market Street
Philadelphia, PA. 19103
763
Keystone Health Plan West
PO Box 898819
Camp Hill, PA 17089
765
Prudential Health Care Plan
P.O. Box 901
Horsham, PA. 19044
September 2010
Page 34
™
Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Carrier Code
Carrier Name
Address
766
Healthnet of the Northeast
P.O. Box 14700
Lexington, KY 40512
767
Aetna/US Healthcare
Pittsburgh
Terminated 08/12/2005
5313 Campbells Run Road
Pittsburgh, PA. 15205
768
Aetna/US Healthcare/HMO PA P.O. Box 1109
Terminated 08/12/2005
Blue Bell, PA. 19422
770
Health Partners/Senior Partners PO Box 5194
of Philadelphia (Terminated
New York, NY 10004-5194
6/30/06)
Use code 503.
771
Horizon Healthcare
Terminated 12/31/2000
1700 Market Street
Philadelphia, PA. 19103
772
HIP Health Plan of PA
6 Neshaminy Interplex
Trevose, PA. 19053
774
UPMC Health Plan Inc
PO Box 2999
Pittsburgh, PA. 15230
775
Optimum Choice Inc of PA
PO Box 930
Frederick, MD 21705
776
Philcare Health Systems
2005 Market Street
Philadelphia, PA. 19103
777
Health Central
Terminated 12/31/2001
2605 Interstate Drive
Harrisburg, PA. 17110
778
Amerihealth HMO
1901 Market Street
Philadelphia, PA 19103
779
Health Plans of PA
100 W Sproul Road - 3Rd Floor
Springfield, PA 19064
780
Principal HealthCare of PA
2751 Centerville Road
Wilmington, DE 19808
September 2010
Page 35
™
Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Carrier Code
Carrier Name
Address
781
Avalon Health Ltd.
2500 Elmerton Avenue
Harrisburg, PA 17110
783
Qualmed Plans For Health
1835 Market Street
Philadelphia, PA 19103
784
Physicians Care HMO
651 East Park Drive, Suite 108
Harrisburg, PA 17111
798
Other HMO
799
Commercial Insurance (Not
Otherwise Listed)
801
Auto Insurance Terminated
5/24/07
802
Workers’ Compensation
803
Black Lung Medical Benefits
900
Patient Pay
902
LTC Patient Pay
903
Transfer Penalty
Alphabetical Listing of Insurance Carriers:
Carrier Name
Carrier Code
AARP Medigap
741
Accordia National
735
Advantage Health Plan
753
Advantra (Medicare Advantage)
509
Aetna (Medicare Advantage)
505
September 2010
Page 36
™
Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Carrier Name
Carrier Code
Aetna HMO Health Plans East/Central PA
750
Aetna Life Insurance Co
702
Alliance Health Network
752
Allstate Insurance Company
703
Amalgamated Life Insurance Co
701
American General Ins Co
711
American Postal Workers Union
734
Americhoice Personal Care Plus
751
Amerihealth HMO
778
Amerihealth 65
512
Anthem Blue Cross/Blue Shield (Medicare Advantage)
532
Argus
709
Auto Insurance
801
Avalon Health LTD
781
Bankers Life & Casualty Co
704
Black Lung Medical Benefits
803
Blue Cross Medigap (out of state)
249
Blue Cross of Northeastern PA
203
Blue Cross Out-of-State
299
Blue Shield Medigap (out of state)
349
Blue Shield Medigap Security 65
340
Blue Shield Out-of-State
399
September 2010
Page 37
™
Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Carrier Name
Carrier Code
Bravo Health Pennsylvania (Medicare Advantage)
516
Capital Blue Cross
202
Capital SeniorBlue (Medicare Advantage)
502
Care Improvement Plus (Medicare Advantage)
533
Caremark
749
Champus (Tricare & United Concordia)
400
Champus/VA
401
CIGNA
708
CIGNA Healthcare of PA
754
CIGNA Medicare Access (Medicare Advantage)
542
Citrus Health Care (Medicare Advantage)
529
Combined Insurance Company of America
707
Commercial Insurance (Carrier name not on list)
799
Commercial Medigap Ins. (Not otherwise listed)
740
Compensation
802
Community LIFE (Medicare Advantage)
524
CONSECO
706
Continental Casualty Ins Co
710
Coventry Healthcare (Medicare Advantage)
527
Delta Dental of PA
700
Educators Mutual Life Ins Co
712
Employers Health Insurance Co
736
September 2010
Page 38
™
Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Carrier Name
Carrier Code
Equitable Assurance Soc-US
713
Express Scripts
743
First Priority Health
760
Freedom Blue (Medicare Advantage)
501
Gateway Health Plan Medicare Assured (Medicare Advantage)
506
Geisinger Health Plan
755
Geisinger Health Plan (Medicare Advantage)
511
GHI Medicare Choice (Medicare Advantage)
530
Health Plans of PA
779
HealthAmerica Advantra/Advantra Gold/Advantra Silver (Medicare Advantage)
509
HealthAmerica/Health Assurance
757
HealthAmerica/Health Assurance (Pittsburgh)
758
Healthfirst Medicare Plan (Medicare Advantage)
522
Healthguard of Lancaster
759
HealthMarkets Care Assured (Medicare Advantage)
539
Healthnet of the Northeast
766
Highmark Blue Cross/Blue Shield
201
Highmark Blue Shield
302
Highmark Service Company
244
HIP Health Plan of Greater New York (Medicare Advantage)
537
HIP Health Plan of PA
772
Horizon BC/BS of New Jersey (Medicare Advantage)
521
September 2010
Page 39
™
Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Carrier Name
Carrier Code
Humana (Medicare Advantage)
507
Independence Blue Cross
200
Inter-County Hosp Plan
714
Inter-County Phys Serv Plan
715
Jefferson-Pilot Life Ins Co
737
John Hancock Mutual Life Ins Co
716
Keystone 65 Complete (Medicare Advantage)
514
Keystone Health Plan Central
761
Keystone Health Plan East
762
Keystone Health Plan West
763
Keystone SeniorBlue (Medicare Advantage)
519
Life Insurance Co North America
718
LIFE at Home (Medicare Advantage)
534
LIFE Beaver County (Medicare Advantage)
541
LIFE LUTHERAN (Medicare Advantage)
540
LIFE Pittsburgh (Medicare Advantage)
525
Lincoln National Life Ins Co
719
Long Term Care Patient Pay
902
MD MedicareChoice (Medicare Advantage)
538
Massachusetts Mutual Life Ins Co
720
Medicare A
600
Medicare B
100
September 2010
Page 40
™
Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Carrier Name
Carrier Code
Merck MEDCO
748
Mutual of Omaha Ins Co
722
National Association of Letter Carriers
731
National Pharmaceutical Svc
745
National Vision Administrators
742
New York Life Insurance Co
724
Optimum Choice Inc of PA
775
Other HMO(Must enter name/address)
798
Paid Prescription (Medco)
733
PCS
747
PEBTF(Major Med /Medigap)
744
Pennsylvania Blue Shield (associated with a Blue Cross Plan)
300
People Benefit Life Insurance Company
723
Personal Choice 65/Keystone 65 (Medicare Advantage)
500
Philadelphia American Life Ins
738
Philcare Health Systems
776
Phoenix Mutual Life Ins Co
726
Physicians Care HMO
784
Principal Health Care of PA
780
Protective Life Ins Co
739
Provident Life & Accident Ins
727
Prudential Health Care Plan
765
September 2010
Page 41
™
Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Carrier Name
Carrier Code
Prudential Ins Co of America
728
Qualmed Plans for Health
783
St Agnes LIFE (Medicare Advantage)
526
SecureHorizons (Medicare Advantage)
508
Security 65 Capital Plan
242
Security 65 Highmark Plan
241
Security 65 Independence Plan
240
Security 65 Northeast Plan
243
Security Blue (Medicare Advantage)
504
Senior LIFE Johnstown (Medicare Advantage)
535
Senior Partners (Medicare Advantage)
503
Sterling Option 1 (Medicare Advantage)
510
Today’s Option (Medicare Advantage)
517
Transamerica Occidental Ins Co
725
Trustees of the University of Pennsylvania (Medicare Advantage)
523
UniCare (Medicare Advantage)
531
Unison Advantage (Medicare Advantage)
513
United Concordia
705
United Health Care
721
United HealthCare (Evercare/Erickson Advantage) (Medicare Advantage)
518
Universal American (Medicare Advantage)
543
Universal Health Care (Medicare Advantage)
528
September 2010
Page 42
™
Pennsylvania PROMISe – 835 Remittance Advice Companion Guide
Carrier Name
Carrier Code
UPMC For Life (Medicare Advantage)
515
UPMC Health Plan
774
USACare (Medicare Advantage)
536
Washington National Ins Co
732
WellCare (Medicare Advantage)
520
September 2010
Page 43