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.

Pos	Id	Segment Name	Req	Max Use	Repeat	Notes	Usage
	ISA	Interchange Control Header	M	1			Required
	GS	Functional Group Header	M	1			Required

	Pos	Id	Segment Name	Req	Max Use	Repeat	Notes	Usage
	010	ST	Transaction Set Header	M	1			Required
	020	BPR	Financial Information	M	1			Required
	040	TRN	Reassociation Trace Number	O	1		N1/040	Required
	050	CUR	Foreign Currency Information	O	1		N1/050	Situational
	060	REF	Receiver Identification	O	1			Situational
	060	REF	Version Identification	O	1			Situational
	070	DTM	Production Date	O	1			Recommended
LOOP ID - 1000A						1	N1/080L
	080	N1	Payer Identification	O	1		N1/080	Required
	100	N3	Payer Address	O	1			Required
	110	N4	Payer City, State, ZIP Code	O	1			Required
	120	REF	Additional Payer Identification	O	4			Not recommended
	130	PER	Payer Contact Information	O	1			Situational

LOOP ID - 1000B						1	N1/080L
	080	N1	Payee Identification	O	1		N1/080	Required
	100	N3	Payee Address	O	1			Situational
	110	N4	Payee City, State, ZIP Code	O	1			Situational
	120	REF	Payee Additional Identification	O	>1			Situational

	Pos	Id	Segment Name	Req	Max Use	Repeat	Notes	Usage
LOOP ID - 2000						>1	N2/003L
	003	LX	Header Number	O	1		N2/003	Situational
	005	TS3	Provider Summary Information	O	1			Situational
	007	TS2	Provider Supplemental Summary Information	O	1			Situational
LOOP ID - 2100						>1
	010	CLP	Claim Payment Information	M	1			Required
	020	CAS	Claim Adjustment	O	99		N2/020	Situational
	030	NM1	Patient Name	M	1			Required
	030	NM1	Insured Name	O	1			Situational
	030	NM1	Corrected Patient/Insured Name	O	1			Situational
	030	NM1	Service Provider Name	O	1			Situational
	030	NM1	Crossover Carrier Name	O	1			Situational
	030	NM1	Corrected Priority Payer Name	O	2			Situational
	033	MIA	Inpatient Adjudication Information	O	1			Situational
	035	MOA	Outpatient Adjudication Information	O	1			Situational
	040	REF	Other Claim Related Identification	O	5			Situational
	040	REF	Rendering Provider Identification	O	10			Situational
	050	DTM	Claim Date	O	4			Situational
	060	PER	Claim Contact Information	O	3			Situational
	062	AMT	Claim Supplemental Information	O	14			Situational
	064	QTY	Claim Supplemental Information Quantity	O	15			Situational
LOOP ID - 2110						999
	070	SVC	Service Payment Information	O	1			Recommended
	080	DTM	Service Date	O	3		N2/080	Situational
	090	CAS	Service Adjustment	O	99		N2/090	Situational
	100	REF	Service Identification	O	7			Situational
	100	REF	Rendering Provider Information	O	10			Situational
	110	AMT	Service Supplemental Amount	O	12			Situational
	120	QTY	Service Supplemental Quantity	O	6			Situational
	130	LQ	Health Care Remark Codes	O	99			Situational

Pos	Id	Segment Name	Req	Max Use	Repeat	Notes	Usage
010	PLB	Provider Adjustment	O	>1			Situational
020	SE	Transaction Set Trailer	M	1			Required

Pos	Id	Segment Name	Req	Max Use	Repeat	Notes	Usage
	GE	Functional Group Trailer	M	1			Required
	IEA	Interchange Control Trailer	M	1			Required

1/040	The TRN segment is used to uniquely identify a claim payment and advice.
1/050	The CUR segment does not initiate a foreign exchange transaction.
1/080L	The N1 loop allows for name/address information for the payer and payee which would be utilized to address remittance(s) for delivery.
1/080	The N1 loop allows for name/address information for the payer and payee which would be utilized to address remittance(s) for delivery.
1/080L	The N1 loop allows for name/address information for the payer and payee which would be utilized to address remittance(s) for delivery.
1/080	The N1 loop allows for name/address information for the payer and payee which would be utilized to address remittance(s) for delivery.
2/003L	The LX segment is used to provide a looping structure and logical grouping of claim payment information.
2/003	The LX segment is used to provide a looping structure and logical grouping of claim payment information.
2/020	The CAS segment is used to reflect changes to amounts within Table 2.
2/080	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.
2/090	The CAS segment is used to reflect changes to amounts within Table 2.