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Updated:09/19/2008

HIPAA 835 Health Care Claim Payment/Advice
Management Systems Consulting, Inc.
VERSION: 1.0 DRAFT

Author: Skip Stein

Notes: In order to protect the security and confidentiality of electronic health information, Congress has passed The Health Insurance Portability and Accountability Act, also known as HIPAA, which was the result of efforts by the Clinton Administration and congressional healthcare reform proponents to reform healthcare in a way that would streamline industry inefficiencies, reduce paperwork, make it easier to detect and prosecute fraud and abuse and enable workers of all professions to change jobs, even if they (or family members) had pre-existing medical conditions.

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:
Pos Id Segment Name Req Max Use Repeat Notes Usage
010 ST Transaction Set Header M 1
020 BPR Financial Information M 1
040 TRN Reassociation Trace Number O 1 N1/040
050 CUR Foreign Currency Information O 1 N1/050
060 REF Receiver Identification O 1
060 REF Version Identification O 1
070 DTM Production Date O 1
Loop ID - 1000A 1
080 N1 Payer Identification O 1 N1/080
100 N3 Payer Address O 1
110 N4 Payer City, State, ZIP Code O 1
120 REF Additional Payer Identification O 4
130 PER Payer Contact Information O 1
Loop ID - 1000B 1
080 N1 Payee Identification O 1 N1/080
100 N3 Payee Address O 1
110 N4 Payee City, State, ZIP Code O 1
120 REF Payee Additional Identification O >1
Detail:
Pos Id Segment Name Req Max Use Repeat Notes Usage
Loop ID - 2000 >1
003 LX Header Number O 1 N2/003
005 TS3 Provider Summary Information O 1
007 TS2 Provider Supplemental Summary Information O 1
Loop ID - 2100 >1
010 CLP Claim Payment Information M 1
020 CAS Claim Adjustment O 99 N2/020
030 NM1 Patient Name M 1
030 NM1 Insured Name O 1
030 NM1 Corrected Patient/Insured Name O 1
030 NM1 Service Provider Name O 1
030 NM1 Crossover Carrier Name O 1
030 NM1 Corrected Priority Payer Name O 2
033 MIA Inpatient Adjudication Information O 1
035 MOA Outpatient Adjudication Information O 1
040 REF Other Claim Related Identification O 5
040 REF Rendering Provider Identification O 10
050 DTM Claim Date O 4
060 PER Claim Contact Information O 3
062 AMT Claim Supplemental Information O 14
064 QTY Claim Supplemental Information Quantity O 15
Loop ID - 2110 999
070 SVC Service Payment Information O 1
080 DTM Service Date O 3 N2/080
090 CAS Service Adjustment O 99 N2/090
100 REF Service Identification O 7
100 REF Rendering Provider Information O 10
110 AMT Service Supplemental Amount O 12
120 QTY Service Supplemental Quantity O 6
130 LQ Health Care Remark Codes O 99
Summary:
Pos Id Segment Name Req Max Use Repeat Notes Usage
010 PLB Provider Adjustment O >1
020 SE Transaction Set Trailer M 1

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