Note: The Requirement Designator (Req. Des.) is based on Novant Health s requirements.
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1 810 ANSI X12 Version INVOICE SPECS FUNCTIONAL GROUP IN This transaction set is used by Novant Health to establish billing for goods and services provided by our vendors to us. Note: The Requirement Designator ( ) is based on Novant Health s requirements. Table 1 Header Position Number Max Use 010 ST Transaction Set Header M BIG Beginning for Invoice M 1 Loop Repeat Table 2 Detail Position Number Max Use Loop Repeat LOOP ID IT IT1 Baseline Item (Invoice) M 1 Table 3 Total Position Number Max Use 010 TDS Total Monetary Value Summary M TXI Tax Information O 10 Loop Repeat LOOP ID SAC SAC Service, Promotion, Allowance, or Charge Info O SE Transaction Set Trailer M 1 Page 1 of 10 2/6/2009
2 ST 010 Transaction Set Header To indicate the start of a transaction set and to assign a control number Mandatory ST Transaction Set Code M ID 3/3 To indicate the start of a transaction set and to assign a control number Value = 810 ST Transaction Set Control Number M AN 4/9 Control Number assigned by customer. The value must match the value specified in element SE02. ST*810* ! Page 2 of 10 2/6/2009
3 BIG 020 Beginning for Invoice To indicate the beginning of an invoice transaction set and transmit identifying numbers and dates. Mandatory BIG Invoice Date M DT 8/8 The date that was assigned to the invoice by the vendor. (Who we purchased the product from) BIG02 76 Invoice Number M AN 1/22 The invoice number assigned by the vendor. (Who we purchased the product from). BIG Purchase Order Date Not Used BIG Purchase Order Number M AN 1/22 The purchase order number that was originally sent by Novant Health which this invoice refers BIG Release Number Not Used BIG Change Order Sequence Number Not Used BIG Transaction Code O ID 2/2 of invoice sent Value DI CR Usage Debit Invoice Credit Memo BIG Transaction Set Purpose Code Not Used BIG Action Code Not Used BIG10 76 Invoice Number Not Used BIG* * * *245836***DI! Page 3 of 10 2/6/2009
4 IT1 010 Baseline Item (Invoice) To specify the basic and most frequently used line item data for the invoice and related transactions. Mandatory IT Assigned Identification M AN 1/20 PO (purchase order) line number should be returned on the invoice so there is a perfect match. IT Quantity Invoiced M R 1/10 Quantity Amount Invoiced IT Unit or Basis for Measure Code M ID 2/2 IT Unit Price M R 1/17 Unit Price for item IT Basis of Unit Price Code Not Used IT Product/Service ID Qualifier M ID 2/2 Code specifying type of Product number being sent Value VC Usage Vendor Catalog Number IT Product/Service ID M AN 1/48 Vendor s Item Number IT Product/Service ID Qualifier M ID 2/2 Code specifying type of Product number being sent Value IN Usage Buyer s Item Number (Novant Health s item number) IT Product/Service ID M AN 1/48 Novant s Item Number IT Product/Service ID Qualifier Not Used IT Product/Service ID Not Used IT Product/Service ID Qualifier Not Used IT Product/Service ID Not Used Page 4 of 10 2/6/2009
5 IT Product/Service ID Qualifier Not Used IT Product/Service ID Not Used IT Product/Service ID Qualifier Not Used IT Product/Service ID Not Used IT Product/Service ID Qualifier Not Used IT Product/Service ID Not Used IT Product/Service ID Qualifier Not Used IT Product/Service ID Not Used IT Product/Service ID Qualifier Not Used IT Product/Service ID Not Used IT Product/Service ID Qualifier Not Used IT Product/Service ID Not Used IT1*1*2*EA*40.44**VC* *IN*42135! Page 5 of 10 2/6/2009
6 TDS 010 Total Monetary Value Summary To specify the total invoice discounts and amounts Mandatory TDS Amount M N2 1/15 Total Amount of Invoice TDS Amount Not Used TDS Amount Not Used TDS Amount Not Used TDS*8654! Page 6 of 10 2/6/2009
7 TXI 020 Tax Information To specify tax information Optional TXI Tax Code M ID 2/2 Any valid Tax Code TXI Monetary Amount M R 1/18 Tax Amount due on Invoice TXI Percent Not Used TXI Tax Jurisdiction Code Qualifier Not Used TXI Tax Jurisdiction Code Not Used TXI Tax Exempt Code Not Used TXI Relationship Code Not Used TXI Dollar Basis for Percent Not Used TXI Tax Identification Number Not Used TXI Assigned Identification Not Used TXI*FT*5.66! Page 7 of 10 2/6/2009
8 SAC 040 Service, Promotion, Allowance, or Charge Information To request or identify a service, promotion, allowance or charge; to specify the amount or percentage for the service, promotion, allowance or charge. Optional SAC Allowance or Charge Indicator M ID 1/1 Any Valid Allowance or Charge Indicator SAC Service, Promotion, Allowance, or Charge Code Any Valid Code M ID 4/4 SAC Agency Qualifier Code Not Used SAC Agency Service, Promotion Allowance, or Charge Code Not Used SAC Amount M N2 1/15 Charge Amount SAC Allowance/Charge Percent Qualifier Not Used SAC Percent Not Used SAC Rate Not Used SAC Unit or Basis for Measurement Code Not Used SAC Quantity Not Used SAC Quantity Not Used SAC Allowance or Charge Method of Handling Code Not Used SAC Reference Identification Not Used SAC Option Number Not Used SAC Description O AN 1/80 Description of Charge SAC Language Code Not Used SAC*C*D240***1243**********Freight! Page 8 of 10 2/6/2009
9 CTT 070 Transaction Totals To transmit a hash total for a specific element in the transaction set. Optional CTT Number of Line Items M N0 1/6 The total number of line items CTT Hash Total Not Used CTT03 81 Weight Not Used CTT Unit or Basis for Measurement Code Not Used CTT Volume Not Used CTT Unit or Basis for Measurement Code Not Used CTT Description Not Used CTT*1! Page 9 of 10 2/6/2009
10 SE 080 Transaction Set Trailer To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments). Mandatory SE01 96 Number of Included s M N0 1/10 Total number of segments included in a transaction set including ST and SE segments. SE 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. This value must be identical to that specified in the ST02 element. SE*11* ! Page 10 of 10 2/6/2009
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811 Consolidated Service Invoice/Statement Functional Group ID=CI
811 Consolidated Service Invoice/Statement Functional Group ID=CI Introduction This Draft Standard for Trial Use contains the format and establishes the data contents of the Consolidated Service Invoice/Statement