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) 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.

  • ST
    Transaction Set Header
    M必须(Mandatory)
    Repeat 1

    To indicate the start of a transaction set and to assign a control number

  • BPR
    Beginning Segment for Payment Order/Remittance Advice
    M必须(Mandatory)
    Repeat 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

  • NTE
    Note/Special Instruction
    O可选(Optional)
    Repeat > 1

    To transmit information in a free-form format, if necessary, for comment or special instruction

  • TRN
    Trace
    O可选(Optional)
    Repeat 1

    To uniquely identify a transaction to an application

  • CUR
    Currency
    O可选(Optional)
    Repeat 1

    To specify the currency (dollars, pounds, francs, etc.) used in a transaction

  • REF
    Reference Identification
    O可选(Optional)
    Repeat > 1

    To specify identifying information

  • DTM
    Date/Time Reference
    O可选(Optional)
    Repeat > 1

    To specify pertinent dates and times

  • N1Loop1Name LOOPO可选(Optional)Repeat 200
    N1N2N3N4REFPER
    • N1
      Name
      M必须(Mandatory)
      Repeat 1

      To identify a party by type of organization, name, and code

    • N2
      Additional Name Information
      O可选(Optional)
      Repeat > 1

      To specify additional names or those longer than 35 characters in length

    • N3
      Address Information
      O可选(Optional)
      Repeat > 1

      To specify the location of the named party

    • N4
      Geographic Location
      O可选(Optional)
      Repeat 1

      To specify the geographic place of the named party

    • REF
      Reference Identification
      O可选(Optional)
      Repeat > 1

      To specify identifying information

    • PER
      Administrative Communications Contact
      O可选(Optional)
      Repeat > 1

      To identify a person or office to whom administrative communications should be directed

  • LXLoop1Assigned Number LOOPO可选(Optional)Repeat > 1
    LXTS3TS2CLPLoop1
    • LX
      Assigned Number
      M必须(Mandatory)
      Repeat 1

      To reference a line number in a transaction set

    • TS3
      Transaction Statistics
      O可选(Optional)
      Repeat 1

      To supply provider-level control information

    • TS2
      Transaction Supplemental Statistics
      O可选(Optional)
      Repeat 1

      To provide supplemental summary control information by provider fiscal year and bill type

    • CLPLoop1Claim Level Data LOOPM必须(Mandatory)Repeat > 1
      CLPCASNM1MIAMOAREFDTMPERAMTQTYSVCLoop1
      • CLP
        Claim Level Data
        M必须(Mandatory)
        Repeat 1

        To supply information common to all services of a claim

      • CAS
        Claims Adjustment
        M必须(Mandatory)
        Repeat 99

        To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

      • NM1
        Individual or Organizational Name
        M必须(Mandatory)
        Repeat 9

        To supply the full name of an individual or organizational entity

      • MIA
        Medicare Inpatient Adjudication
        O可选(Optional)
        Repeat 1

        To provide claim-level data related to the adjudication of Medicare inpatient claims

      • MOA
        Medicare Outpatient Adjudication
        O可选(Optional)
        Repeat 1

        To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting

      • REF
        Reference Identification
        O可选(Optional)
        Repeat 99

        To specify identifying information

      • DTM
        Date/Time Reference
        O可选(Optional)
        Repeat 9

        To specify pertinent dates and times

      • PER
        Administrative Communications Contact
        O可选(Optional)
        Repeat 3

        To identify a person or office to whom administrative communications should be directed

      • AMT
        Monetary Amount
        O可选(Optional)
        Repeat 20

        To indicate the total monetary amount

      • QTY
        Quantity
        O可选(Optional)
        Repeat 20

        To specify quantity information

      • SVCLoop1Service Information LOOPO可选(Optional)Repeat 999
        SVCDTMCASREFAMTQTYLQ
        • SVC
          Service Information
          M必须(Mandatory)
          Repeat 1

          To supply payment and control information to a provider for a particular service

        • DTM
          Date/Time Reference
          O可选(Optional)
          Repeat 9

          To specify pertinent dates and times

        • CAS
          Claims Adjustment
          O可选(Optional)
          Repeat 99

          To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

        • REF
          Reference Identification
          O可选(Optional)
          Repeat 99

          To specify identifying information

        • AMT
          Monetary Amount
          O可选(Optional)
          Repeat 20

          To indicate the total monetary amount

        • QTY
          Quantity
          O可选(Optional)
          Repeat 20

          To specify quantity information

        • LQ
          Industry Code
          O可选(Optional)
          Repeat 99

          Code to transmit standard industry codes

  • PLB
    Provider Level Adjustment
    O可选(Optional)
    Repeat > 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

  • SE
    Transaction Set Trailer
    M必须(Mandatory)
    Repeat 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)

Segment
X12 EDI Release 00306
To indicate the start of a transaction set and to assign a control number
Elements
  • ST01143Transaction Set Identifier Code
    ID
    M必须(Mandatory)
    Min 3 / Max 3

    Code uniquely identifying a Transaction Set

    Codes (320)
  • ST02329Transaction Set Control Number
    AN
    M必须(Mandatory)
    Min 4 / Max 9

    Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

  • ST031705Implementation Convention Preference
    AN
    O可选(Optional)
    Min 1 / Max 9