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Transaction Set
in
X12 Release 003030

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.

Heading

Sequence
Segment
Name
Max use
010
Transaction Set HeaderMandatory
Max 1
To indicate the start of a transaction set and to assign a control number
020
Beginning Segment for Payment Order/Remittance AdviceMandatory
Max 1
To (1) indicate the beginning of a Payment Order/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
030
Note/Special Instruction
Max >1
To transmit information in a free-form format, if necessary, for comment or special instruction
040
Trace
Max 1
To uniquely identify a transaction to an application.
The TRN segment is used to uniquely identify a claim payment and advice.
050
Currency
Max 1
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
The CUR segment does not initiate a foreign exchange transaction.
060
Reference Numbers
Max >1
To specify identifying numbers.
070
Date/Time Reference
Max >1
To specify pertinent dates and times
N1 Loop
Repeat 200
080
Name
Max 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.
090
Additional Name Information
Max >1
To specify additional names or those longer than 35 characters in length
100
Address Information
Max >1
To specify the location of the named party
110
Geographic Location
Max 1
To specify the geographic place of the named party
120
Reference Numbers
Max >1
To specify identifying numbers.
130
Administrative Communications Contact
Max >1
To identify a person or office to whom administrative communications should be directed

Detail

Sequence
Segment
Name
Max use
LX Loop
Repeat >1
003
Assigned Number
Max 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.
005
Transaction Statistics
Max 1
To supply provider level summary of control information by provider fiscal year and bill type
007
Transaction Supplemental Statistics
Max 1
To provide supplemental summary control information by provider fiscal year and bill type
CLP Loop
Repeat >1
010
Claim Level DataMandatory
Max 1
To supply information common to all services of a claim
020
Claims AdjustmentMandatory
Max 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.
030
Individual or Organizational NameMandatory
Max 9
To supply the full name of an individual or organizational entity
033
Medicare Inpatient Adjudication
Max 1
To provide claim level data related to the adjudication of Medicare patient claims
035
Medicare Outpatient Adjudication
Max 1
To convey claim level data related to the adjudication of Medicare Outpatient claims
040
Reference Numbers
Max 99
To specify identifying numbers.
050
Date/Time Reference
Max 9
To specify pertinent dates and times
060
Administrative Communications Contact
Max 3
To identify a person or office to whom administrative communications should be directed
SVC Loop
Repeat 999
070
Service Information
Max 1
To supply payment and control information to a provider for a particular service
080
Date/Time ReferenceMandatory
Max 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.
090
Claims Adjustment
Max 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.
100
Reference Numbers
Max 99
To specify identifying numbers.

Summary

Sequence
Segment
Name
Max use
010
Provider Level Adjustment
Max 99
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
020
Transaction Set TrailerMandatory
Max 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).
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Stedi is a registered trademark of Stedi, Inc. Stedi's EDI Reference and Mapping Guides are provided for marketing purposes and are free of charge. All names, logos, and brands of third parties listed on our site are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Our use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.