EDI 835Health Care Claim Payment Advice

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 Claim Payment/Advice?

Healthcare providers submit electronic claims for services using the EDI 835, which payers process for reimbursement.

How is an EDI 835 used?

It ensures accurate, efficient sharing of claim information and expedites payments between payers, clearinghouses, and providers.

Segments

Position
Segment
Name
Max use
10
ST
Transaction Set Header
Mandatory
AtMax 1
To indicate the start of a transaction set and to assign a control number
20
BPR
Beginning Segment for Payment Order/Remittance Advice
Mandatory
AtMax 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
30
NTE
Note/Special Instruction
Opt
GT 1
To transmit information in a free-form format, if necessary, for comment or special instruction
40
TRN
Trace
Opt
AtMax 1
To uniquely identify a transaction to an application
50
CUR
Currency
Opt
AtMax 1
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
60
REF
Reference Identification
Opt
GT 1
To specify identifying information
70
DTM
Date/Time Reference
Opt
GT 1
To specify pertinent dates and times
1000
LOOP
Opt
AtMax 200
2000
LOOP
Opt
GT 1
10
PLB
Provider Level Adjustment
Opt
GT 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
20
SE
Transaction Set Trailer
Mandatory
AtMax 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)

Elements

PositionElementNameRequirementTypeMin/MaxRepeat
1
143
Transaction Set Identifier CodeMandatoryID3/31
2
329
Transaction Set Control NumberMandatoryAlphanumeric4/91