EDI 835 Health Care Claim Payment/Advice Transaction Specifications

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 EDI 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 EDI healthcare 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. To ensure you meet HIPAA 5010 requirements, nothing else compares to EDI/HQ™ Healthcare. You get the extensive features of our advanced EDI software, with full HIPAA compliance built right in. Contact 1 EDI Source today for a demonstration.

EDI 835 Format

ISA*01*0000000000*01*0000000000*ZZ*ABCDEFGHIJKLMNO*ZZ*123456789012345*101127*1719*U*00400*000003438*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*SQUAREPANTS*BOB* ***MI*2222222
NM1*82*2*BIKINI AGENCY*****FI*310626223
REF*F8*H57B10401
SVC*ZZ:M151000:F0*162.13*0**1.9
DTM*472*20020920
CAS*CO*29*162.13*0*42*0*0
REF*6R*888888
CLP*111111*2*56.52*18.88*0*13*0000000644444444*53
NM1*QC*1*LEGHORN*FOGHORN*P***MI*7777777
NM1*82*2*CHICKENHAWK SVCS*****FI*346608640
REF*F8*A76B04054
SVC*HC:H0005:HF:H9*56.52*18.88**6
DTM*472*20031209
CAS*CO*42*0*0
CAS*OA*23*37.64*0
REF*6R*111111
CLP*121212*4*56.52*0*0*13*0000000646464640*53
NM1*QC*1*EXPLORER*DORA****MI*1717171
NM1*82*2*SWIPER AGENCY*****FI*346608640
REF*F8*A76B04054
SVC*HC:H0005:HF:H9*56.52*0**6
DTM*472*20031202
CAS*CO*42*0*0
CAS*OA*23*57.6*0*23*-1.08*0
REF*6R*121212
CLP*333333*1*74.61*59.69*14.92*13*0000000688888888*55
NM1*QC*1*BEAR*YOGI* ***MI*2222222
NM1*82*2*JELLYSTONE SVCS*****FI*346608640
REF*F8*A76B04054
SVC*ZZ:A0230:HF*74.61*59.69**1
DTM*472*20110203
CAS*PR*2*14.92*0
CAS*CO*42*0*0
REF*6R*333333
CLP*777777*25*136.9*0*0*13*0000000622222222*53
NM1*QC*1*BIRD*TWEETY*M***MI*4444444
NM1*82*2*GRANNY AGENCY*****FI*340716747
REF*F8*A76B03293
SVC*HC:H0015:HF:99:H9*136.9*0**1
DTM*472*20030911
CAS*PI*104*136.72*0
CAS*CO*42*0.18*0
REF*6R*777777
CLP*123456*22*-42.58*-42.58*0*13*0000000657575757*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

EDI 835 Specification

This 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 EDI healthcare 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.

Sources

Accredited Standards Committee X12. ASC X12 Standard [Table Data]. Data Interchange Standards Association, Inc., Falls Church, VA. http://www.x12.org

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