X12 HIPAA 835 Payment

The EDI 835 transaction set is called Health Care Claim Payment and Remittance Advice. It has been specified by HIPAA 5010 requirements for the electronic transmission of healthcare payment and benefit information. The EDI 835 is used primarily by Healthcare insurance plans to make payments to healthcare providers, to provide Explanations of Benefits (EOBs) or both. When a healthcare service provider submits an 837 Health Care Claim, the insurance plan uses the 835 to detail the payment to that claim, including:

• What charges were paid, reduced, or denied
• Whether there was a deductible, co-insurance, co-pay, etc.
• Any bundling or splitting of claims or line items
• How the payment was made, such as through a clearinghouse

A particular 835 EDI healthcare document may not necessarily match up one-for-one with a specific 837. In fact, it is not uncommon for multiple 835 transactions to be used in response to a single 837, or for one 835 to address multiple 837 submissions. As a result, the 835 is important to healthcare providers, to track what payments were received for services they provided and billed.

X12 HIPAA 835 Specification

X12 HIPAA 835 specification is available at:

• EdiNation

X12 HIPAA 835 Code Example

X12 HIPAA 835 code example is available at:

• EDI Tools for .NET X12 HIPAA 835 parse & generate C# example

X12 HIPAA 835 Sample File

ISA*00*          *00*          *ZZ*1234567        *ZZ*11111          *170508*1141*^*00501*000000101*1*P*:~
GS*HC*XXXXXXX*XXXXX*20170617*1741*101*X*005010X221A1~
ST*835*0001~
BPR*I*34.00*C*CHK************20050318~
TRN*1*0063158ABC*1566339911~
REF*EV*030240928~
DTM*405*20050318~
N1*PR*YOUR TAX DOLLARS AT WORK~
N3*481A00 DEER RUN ROAD~
N4*WEST PALM BCH*FL*11114~
PER*BL*JOHN WAYNE*TE*8005551212*EX*123~
N1*PE*ATONEWITHHEALTH*FI*3UR334563~
N3*3501 JOHNSON STREET~
N4*SUNSHINE*FL*12345~
REF*PQ*11861~
LX*1~
CLP*0001000055*2*541*34**12*50650619501~
NM1*QC*1*BURCK*RAYMOND*W***MI*987654321~
NM1*82*2*PROFESSIONAL TEST 1*****BS*34426~
DTM*232*20050202~
DTM*233*20050202~
SVC*HC:55669*541*34*1~
DTM*472*20050202~
CAS*OA*23*516~
CAS*OA*94*-9~
REF*1B*44280~
AMT*B6*550~
SE*26*0001~
GE*1*101~
IEA*1*000000101~