EDI 835 Health 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.

Segments

Position
Segment
Name
Max use
100
ST
Transaction Set Header
Mandatory
AtMax 1
To indicate the start of a transaction set and to assign a control number
200
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
300
NTE
Note/Special Instruction
Opt
GT 1
To transmit information in a free-form format, if necessary, for comment or special instruction
400
TRN
Trace
Opt
AtMax 1
To uniquely identify a transaction to an application
500
CUR
Currency
Opt
AtMax 1
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
600
REF
Reference Identification
Opt
GT 1
To specify identifying information
700
DTM
Date/Time Reference
Opt
GT 1
To specify pertinent dates and times
1000
LOOP
Opt
AtMax 200
2000
LOOP
Opt
GT 1
100
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
200
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
3
1705
Implementation Convention ReferenceOptAlphanumeric1/351