EDI 835 Health Care Claim Payment/Advice

Functional Group HP

X12N Insurance Subcommittee

This Draft Standard for Trial Use contains the format and establishes the data contents of the Health Care Claim Payment/Advice Transaction Set (835) 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.

What is an EDI 835?

An EDI 835 Health Care Claim Payment/Advice communicates healthcare claim payment information, sent from insurance providers to healthcare agencies. It contains information about what charges have been paid, reduced or denied, deductible, co-insurance or co-pay amounts, bundling/splitting of claims, and how the payment was made (CLP segment). It must be 005010 HIPAA compliant.

How is an EDI 835 used?

For example, when Person A receives an x-ray, Hospital B will issue an EDI 837 Healthcare Claim to Medical Insurance Provider C. Insurance Provider C will respond to the EDI 837 Healthcare Claim an EDI 835 Health Care Claim Payment/Advice to provide payment or further details.

Heading

1. 010 · ST · Transaction Set Header · Max 1 · Mandatory

   To indicate the start of a transaction set and to assign a control number

2. 020 · BPR · Beginning Segment for Payment Order/Remittance Advice · Max 1 · Mandatory

   To (1) indicate the beginning of a Payment Order/Remittance Advice Transaction Set and Total Payment Amount or (2) to enable related transfer of funds and/or information from payer to payee to occur

3. 030 · NTE · Note/Special Instruction · Max >1 · Optional

   To transmit information in a free-form format, if necessary, for comment or special instruction

4. 040 · TRN · Trace · Max 1 · Optional

   To uniquely identify a transaction to an application.

   The TRN segment is used to uniquely identify a claim payment and advice.

5. 050 · CUR · Currency · Max 1 · Optional

   To specify the currency (dollars, pounds, francs, etc.) used in a transaction

   The CUR segment does not initiate a foreign exchange transaction.

6. 060 · REF · Reference Numbers · Max >1 · Optional

   To specify identifying numbers.

7. 070 · DTM · Date/Time Reference · Max >1 · Optional

   To specify pertinent dates and times

8. N1 Loop Optional Repeat 200

   1. 080 · N1 · Name · Max 1 · Mandatory

      To identify a party by type of organization, name and code

      The N1 loop allows for name/address information for the payer and payee which would be utilized to address remittance(s) for delivery.

   2. 090 · N2 · Additional Name Information · Max >1 · Optional

      To specify additional names or those longer than 35 characters in length

   3. 100 · N3 · Address Information · Max >1 · Optional

      To specify the location of the named party

   4. 110 · N4 · Geographic Location · Max 1 · Optional

      To specify the geographic place of the named party

   5. 120 · REF · Reference Numbers · Max >1 · Optional

      To specify identifying numbers.

   6. 130 · PER · Administrative Communications Contact · Max >1 · Optional

      To identify a person or office to whom administrative communications should be directed

Detail

1. CLP Loop Mandatory Repeat >1

   1. 010 · CLP · Claim Level Data · Max 1 · Mandatory

      To supply information common to all services of a claim

      Table 2 is used to convey explanation of benefit and remittance advice information.

   2. 020 · CAS · Claims Adjustment · Max 99 · Mandatory

      To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

      The CAS segment appears once for each adjustment. It is used to reflect changes to any and all amounts within Table 2.

   3. 030 · NM1 · Individual Name · Max 9 · Mandatory

      To supply the full name of an individual

   4. 040 · REF · Reference Numbers · Max 99 · Optional

      To specify identifying numbers.

   5. 050 · DTM · Date/Time Reference · Max 9 · Optional

      To specify pertinent dates and times

   6. 060 · PER · Administrative Communications Contact · Max 3 · Optional

      To identify a person or office to whom administrative communications should be directed

   7. SVC Loop Optional Repeat 999

      1. 070 · SVC · Service Information · Max 1 · Mandatory

         To supply payment and control information to a provider for a particular service

      2. 080 · DTM · Date/Time Reference · Max 9 · Mandatory

         To specify pertinent dates and times

         The DTM segment in the SVC loop is to be used to express dates and date ranges specifically related to the service identified in the SVC segment.

      3. 090 · CAS · Claims Adjustment · Max 9 · Optional

         To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

         The CAS segment appears once for each adjustment. It is used to reflect changes to any and all amounts within Table 2.

      4. 100 · REF · Reference Numbers · Max 99 · Optional

         To specify identifying numbers.

2. 110 · SE · Transaction Set Trailer · Max 1 · Mandatory

   To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments).