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

   (1) To indicate the beginning of a PaymentOrder/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. LX Loop Optional Repeat >1

   1. 003 · LX · Assigned Number · Max 1 · Mandatory

      To reference a line number in a transaction set.

      The LX segment is used to provide a looping structure and logical grouping of claim payment information.

   2. 005 · TS3 · Transaction Statistics · Max 1 · Optional

      To supply provider level summary of control information by provider fiscal year and bill type

   3. 007 · TS2 · Transaction Supplemental Statistics · Max 1 · Optional

      To provide supplemental summary control information by provider fiscal year and bill type

   4. CLP Loop Mandatory Repeat >1

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

         To supply information common to all services of a claim

      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 is used to reflect changes to amounts within Table 2.

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

         To supply the full name of an individual or organizational entity

      4. 033 · MIA · Medicare Inpatient Adjudication · Max 1 · Optional

         To provide claim-level data related to the adjudication of Medicare inpatient claims

      5. 035 · MOA · Medicare Outpatient Adjudication · Max 1 · Optional

         To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting

      6. 040 · REF · Reference Numbers · Max 99 · Optional

         To specify identifying numbers.

      7. 050 · DTM · Date/Time Reference · Max 9 · Optional

         To specify pertinent dates and times

      8. 060 · PER · Administrative Communications Contact · Max 3 · Optional

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

      9. 062 · AMT · Monetary Amount · Max 20 · Optional

         To indicate the total monetary amount.

      10. 064 · QTY · Quantity · Max 20 · Optional

          To specify quantity information.

      11. 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 99 · 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 is used to reflect changes to amounts within Table 2.

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

             To specify identifying numbers.

          5. 110 · AMT · Monetary Amount · Max 20 · Optional

             To indicate the total monetary amount.

          6. 120 · QTY · Quantity · Max 20 · Optional

             To specify quantity information.

Summary

1. 010 · PLB · Provider Level Adjustment · Max 99 · Optional

   To convey provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service

2. 020 · 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).