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

Position
Segment
Name
Max use
  1. To indicate the start of a transaction set and to assign a control number

  2. 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

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

  4. To uniquely identify a transaction to an application

    The TRN segment is used to uniquely identify a claim payment and advice.
  5. To specify the currency (dollars, pounds, francs, etc.) used in a transaction

    The CUR segment does not initiate a foreign exchange transaction.
  6. To specify identifying information

  7. To specify pertinent dates and times

  8. 1000 Loop Optional
    Repeat 200
    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.
    2. To specify additional names or those longer than 35 characters in length

    3. To specify the location of the named party

    4. To specify the geographic place of the named party

    5. To specify identifying information

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

Detail

Position
Segment
Name
Max use
  1. 2000 Loop Optional
    Repeat >1
    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.
    2. To supply provider-level control information

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

    4. 2100 Loop Mandatory
      Repeat >1
      1. To supply information common to all services of a claim

      2. 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. To supply the full name of an individual or organizational entity

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

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

      6. To specify identifying information

      7. To specify pertinent dates and times

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

      9. To indicate the total monetary amount

      10. To specify quantity information

      11. 2110 Loop Optional
        Repeat 999
        1. To supply payment and control information to a provider for a particular service

        2. 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. 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. To specify identifying information

        5. To indicate the total monetary amount

        6. To specify quantity information

        7. Code to transmit standard industry codes

Summary

Position
Segment
Name
Max use
  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

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

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