EDI 835 Health Care Claim Payment/Advice

Common T-Sets > X12 EDI T-Sets / EDIFACT EDI T-Sets

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. 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 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