x12 835 Health Care Claim Payment/Advice

835 Specifications

 The x12 Transaction Set 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. This transaction set can be used to make a payment, send an Explanation of Benefits (EOB) remittance advice, or make a payment and send an EOB remittance advice only from a health insurer to a health care provider either directly or via a financial institution.

 The EDI 835 transaction set is called Health Care Claim Payment and Remittance Advice. It has been specified by HIPAA 5010 requirements for the electronic transmission of healthcare payment and benefit information.

 The 835 is used primarily by Healthcare insurance plans to make payments to healthcare providers, to provide Explanations of Benefits (EOBs), or both. When a healthcare service provider submits an 837 Health Care Claim, the insurance plan uses the 835 to detail the payment to that claim, including:

⇰ What charges were paid, reduced or denied
⇰ Whether there was a deductible, co-insurance, co-pay, etc.
⇰ Any bundling or splitting of claims or line items
⇰ How the payment was made, such as through a clearinghouse

 A particular 835 document may not necessarily match up one-for-one with a specific 837. In fact, it is not uncommon for multiple 835 transactions to be used in response to a single 837, or for one 835 to address multiple 837 submissions. As a result, the 835 is important to healthcare providers, to track what payments were received for services they provided and billed.

835 Example

ISA*00* *00* *ZZ*ABCCOM *ZZ*99999999 *040315*1005*U*00401*004075123*0*P~
GS*HP*ABCCOM*01017*20110315*1005*1*X*004010X091A1~
ST*835*07504123~
BPR*H*5.75*C*NON************20110315~
TRN*1*A04B001017.07504*1346000128~
DTM*405*20110308~
N1*PR*ASHTABULA COUNTY ADAMH BD*XX*6457839886~
N3*4817 STATE ROAD SUITE 203~
N4*ASHTABULA*OH*44004~
N1*PE*LAKE AREA RECOVERY CENTER *FI*346608640~
N3*2801 C. COURT~
N4*ASHTABULA*OH*44004~
REF*PQ*1017~
LX*1~
CLP*444444*1*56.70*56.52*0*MC*0000000655555555*53~
NM1*QC*1*FUDD*ELMER*S***MI*1333333~
NM1*82*2*WECOVERWY SVCS*****FI*346608640~
REF*F8*A76B04054~
SVC*HC:H0005:HF:H9*56.70*56.52**6~
DTM*472*20110205~
CAS*CO*42*0.18*0~
REF*6R*444444~
CLP*999999*4*25.95*0*25.95*13*0000000555555555*11~
NM1*QC*1*SAM*YOSEMITE*A***MI*3333333~
NM1*82*2*ACME AGENCY*****FI*310626223~
REF*F8*H57B10401~
SVC*ZZ:M2200:HE*25.95*0**1~
DTM*472*20021224~
CAS*CR*18*25.95*0~
CAS*CO*42*0*0~
REF*6R*999999~
CLP*888888*4*162.13*0*162.13*MC*0000000456789123*11~
NM1*QC*1*SIMPSON*HOMER* ***MI*8787888~
NM1*82*2*DOH GROUP*****FI*310626223~
REF*F8*A57B04033~
SVC*HC:H0036:GT:UK*-42.58*-42.58**-2~
DTM*472*20110102~
CAS*CR*141*0*0*42*0*0*22*0*0~
CAS*OA*141*0*0~
REF*6R*123456~
CLP*090909*22*-86.76*-86.76*0*MC*0000000648484848*53~
NM1*QC*1*DUCK*DAFFY*W***MI*1245849~
NM1*82*2*ABTHSOLUTE HELP*****FI*346608640~
REF*F8*A76B04054~
SVC*HC:H0004:HF:H9*-86.76*-86.76**-4~
DTM*472*20110210~
CAS*CR*22*0*0*42*0*0~
CAS*OA*22*0*0~
REF*6R*090909~
LQ*HE*MA92~
SE*93*07504123~
GE*1*1~
IEA*1*004075123~