835 W1 Healthcare Claim Payment or Advice Example
What is the EDI 835 Transaction Set?
The EDI 835 Healthcare Claim Payment and Remittance Advice transaction set and format have been specified by HIPAA 5010 standards for the electronic exchange of healthcare payment and benefit information. Healthcare insurance plans use EDI 835 to make payments to healthcare providers and/or provide Explanations of Benefits (EOBs).
When an EDI 837 Healthcare Claim is submitted by a healthcare service provider, the healthcare insurance plan uses the 835 to detail the payment to that claim. What charges were paid, denied, or adjusted; the presence of a deductible, co-insurance, co-pay, etc.; bundling or splitting of claims or line items; how payment was made (e.g. clearinghouse). Healthcare providers use the 835 to track what payments were received for the services they provided and billed.
Note: Multiple 835 transactions may be made in response to one 837. Conversely, one 835 response may be made to multiple 837 submissions. Thus, it is best not to expect a single 835 to match one-to-one with a single 837 as a matter of course.
The EDI 835 W1 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. These transactions may be made from a health insurer to a healthcare provider either directly or via a financial institution. Remittance files are used by practices, facilities and billing companies to auto-post claim payments into their systems.
EDI 835 W1 Format Example
Dollars and Data Sent Together
ASC X12 Version: 005010 | Transaction Set: 835 | TR3 ID: 005010X221
Dollars and data are being sent together through the banking system to pay Medicare Part A institutional claims. This scenario depicts the use of the ANSI ASC X12 835 in a governmental institutional environment. The electronic transmission of funds request and the remittance detail are contained within this single 835. In this scenario, one or more Depository Financial Institutions is involved in transferring information from the sender to the receiver. Included are several inpatient and outpatient claim examples.
|N1*PR*INSURANCE COMPANY OF TIMBUCKTU~|
|N3*1 MAIN STREET~|
|N1*PE*REGIONAL HOPE HOSPITAL*XX*6543210903~|
Accredited Standards Committee X12. ASC X12 Standard [Table Data]. Data Interchange Standards Association, Inc., McLean, VA. ASC X12 Examples
X12, chartered by the American National Standards Institute for more than 35 years, develops and maintains EDI standards and XML schemas.