EDI 835 Health Care Claim Payment/Advice
Functional Group HP
X12N Insurance Subcommittee
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 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
- 0100Transaction Set HeaderMandatoryMax 1
To indicate the start of a transaction set and to assign a control number
- 0200Beginning Segment for Payment Order/Remittance AdviceMandatoryMax 1
To indicate the beginning of a Payment Order/Remittance Advice Transaction Set and total payment amount, or to enable related transfer of funds and/or information from payer to payee to occur
- 0300Note/Special InstructionOptionalMax >1
To transmit information in a free-form format, if necessary, for comment or special instruction
- 0400TraceOptionalMax 1
To uniquely identify a transaction to an application
The TRN segment is used to uniquely identify a claim payment and advice. - 0500CurrencyOptionalMax 1
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
The CUR segment does not initiate a foreign exchange transaction. - 0600Reference InformationOptionalMax >1
To specify identifying information
- 0700Date/Time ReferenceOptionalMax >1
To specify pertinent dates and times
- 1000 Loop OptionalRepeat 200
- 0800Party IdentificationMandatoryMax 1
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. - 0900Additional Name InformationOptionalMax >1
To specify additional names
- 1000Party LocationOptionalMax >1
To specify the location of the named party
- 1100Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 1200Reference InformationOptionalMax >1
To specify identifying information
- 1300Administrative Communications ContactOptionalMax >1
To identify a person or office to whom administrative communications should be directed
- 1400Remittance Delivery MethodOptionalMax 1
To identify remittance delivery when remittance is separate from payment
- 1500Date/Time ReferenceOptionalMax 1
To specify pertinent dates and times
- 0800Party IdentificationMandatoryMax 1
Detail
- 2000 Loop OptionalRepeat >1
- 0030Transaction Set Line NumberMandatoryMax 1
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. - 0050Transaction StatisticsOptionalMax 1
To supply provider-level control information
- 0070Transaction Supplemental StatisticsOptionalMax 1
To provide supplemental summary control information by provider fiscal year and bill type
- 2100 Loop MandatoryRepeat >1
- 0100Claim Level DataMandatoryMax 1
To supply information common to all services of a claim
- 0200Claims AdjustmentOptionalMax 99
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. - 0250Reason AdjustmentOptionalMax 99
To supply Claim Adjustment Reason Codes and amounts as needed for an entire claim or for a particular service within the claim being paid
- 0300Individual or Organizational NameMandatoryMax >1
To supply the full name of an individual or organizational entity
- 0330Inpatient AdjudicationOptionalMax 1
To provide claim level data related to the adjudication of inpatient claims
- 0350Outpatient AdjudicationOptionalMax 1
To provide claim level data related to the adjudication of outpatient claims
- 0400Reference InformationOptionalMax 99
To specify identifying information
- 0500Date/Time ReferenceOptionalMax 9
To specify pertinent dates and times
- 0600Administrative Communications ContactOptionalMax 9
To identify a person or office to whom administrative communications should be directed
- 0620Monetary Amount InformationOptionalMax 20
To indicate the total monetary amount
- 0640Quantity InformationOptionalMax 20
To specify quantity information
- 0650File InformationOptionalMax 1
To transmit a fixed-format record or matrix contents
- 2110 Loop OptionalRepeat 999
- 0700Service InformationMandatoryMax 1
To supply payment and control information to a provider for a particular service
- 0800Date/Time ReferenceOptionalMax 9
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. - 0900Claims AdjustmentOptionalMax 99
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. - 0950Reason AdjustmentOptionalMax 99
To supply Claim Adjustment Reason Codes and amounts as needed for an entire claim or for a particular service within the claim being paid
- 1000Reference InformationOptionalMax 99
To specify identifying information
- 1100Monetary Amount InformationOptionalMax 20
To indicate the total monetary amount
- 1200Quantity InformationOptionalMax 20
To specify quantity information
- 1300Industry Code IdentificationOptionalMax 99
To identify standard industry codes
- 1400Tooth IdentificationOptionalMax 32
To identify a tooth by number and, if applicable, one or more tooth surfaces
- 1500File InformationOptionalMax 1
To transmit a fixed-format record or matrix contents
- 0700Service InformationMandatoryMax 1
- 0100Claim Level DataMandatoryMax 1
- 0030Transaction Set Line NumberMandatoryMax 1
Summary
- 0100Provider Level AdjustmentOptionalMax >1
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
- 0200Transaction Set TrailerMandatoryMax 1
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)