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) 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.