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Transaction Set
in
X12 Release 004030

835 Health Care Claim Payment/Advice

Functional Group HP

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.

Heading

Sequence
Segment
Name
Max use
0100
Transaction Set HeaderMandatory
Max 1
To indicate the start of a transaction set and to assign a control number
0200
Beginning Segment for Payment Order/Remittance AdviceMandatory
Max 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
0300
Note/Special Instruction
Max >1
To transmit information in a free-form format, if necessary, for comment or special instruction
0400
Trace
Max 1
To uniquely identify a transaction to an application
The TRN segment is used to uniquely identify a claim payment and advice.
0500
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.
0600
Reference Identification
Max >1
To specify identifying information
0700
Date/Time Reference
Max >1
To specify pertinent dates and times
1000 Loop
Repeat 200
0800
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.
0900
Additional Name Information
Max >1
To specify additional names
1000
Address Information
Max >1
To specify the location of the named party
1100
Geographic Location
Max 1
To specify the geographic place of the named party
1200
Reference Identification
Max >1
To specify identifying information
1300
Administrative Communications Contact
Max >1
To identify a person or office to whom administrative communications should be directed
1400
Remittance Delivery Method
Max 1
To identify remittance delivery when remittance is separate from payment
1500
Date/Time Reference
Max 1
To specify pertinent dates and times

Detail

Sequence
Segment
Name
Max use
2000 Loop
Repeat >1
0030
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.
0050
Transaction Statistics
Max 1
To supply provider-level control information
0070
Transaction Supplemental Statistics
Max 1
To provide supplemental summary control information by provider fiscal year and bill type
2100 Loop
Repeat >1
0100
Claim Level DataMandatory
Max 1
To supply information common to all services of a claim
0200
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.
0300
Individual or Organizational NameMandatory
Max 9
To supply the full name of an individual or organizational entity
0330
Medicare Inpatient Adjudication
Max 1
To provide claim-level data related to the adjudication of Medicare inpatient claims
0350
Medicare Outpatient Adjudication
Max 1
To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting
0400
Reference Identification
Max 99
To specify identifying information
0500
Date/Time Reference
Max 9
To specify pertinent dates and times
0600
Administrative Communications Contact
Max 3
To identify a person or office to whom administrative communications should be directed
0620
Monetary Amount
Max 20
To indicate the total monetary amount
0640
Quantity
Max 20
To specify quantity information
2110 Loop
Repeat 999
0700
Service Information
Max 1
To supply payment and control information to a provider for a particular service
0800
Date/Time Reference
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.
0900
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.
1000
Reference Identification
Max 99
To specify identifying information
1100
Monetary Amount
Max 20
To indicate the total monetary amount
1200
Quantity
Max 20
To specify quantity information
1300
Industry Code
Max 99
Code to transmit standard industry codes

Summary

Sequence
Segment
Name
Max use
0100
Provider Level Adjustment
Max >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
0200
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.