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.
To indicate the start of a transaction set and to assign a control number
To (1) indicate the beginning of a Payment Order/Remittance Advice Transaction Set and Total Payment Amount or (2) to enable related transfer of funds and/or information from payer to payee to occur
To transmit information in a free-form format, if necessary, for comment or special instruction
To uniquely identify a transaction to an application.
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
To specify identifying numbers.
To specify pertinent dates and times
To identify a party by type of organization, name and code
To specify additional names or those longer than 35 characters in length
To specify the location of the named party
To specify the geographic place of the named party
To specify identifying numbers.
To identify a person or office to whom administrative communications should be directed
To reference a line number in a transaction set.
To supply provider level summary of control information by provider fiscal year and bill type
To provide supplemental summary control information by provider fiscal year and bill type
To supply information common to all services of a claim
To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid
To supply the full name of an individual or organizational entity
To provide claim level data related to the adjudication of Medicare patient claims
To convey claim level data related to the adjudication of Medicare Outpatient claims
To specify identifying numbers.
To specify pertinent dates and times
To identify a person or office to whom administrative communications should be directed
To supply payment and control information to a provider for a particular service
To specify pertinent dates and times
To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid
To specify identifying numbers.
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
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments).
