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EDI 835-W1 Format Example

835-W1 Health Care Claim Payment/Advice Example


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 only be made from a health insurer to a health care provider either directly or via a financial institution.

EDI 835-W1 Healthcare Claim Data Loaded into Data Mapping Middleware

 

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.

Transmission Explanation

ST*835*1234~
BPR*C*150000*C*ACH*CTX*01*999999992*DA*123456*1512345678**01*999988880*DA*98765*20020913~
TRN*1*12345*1512345678~
DTM*405*20020916~
N1*PR*INSURANCE COMPANY OF TIMBUCKTU~
N3*1 MAIN STREET~
N4*TIMBUCKTU*AK*89111~
REF*2U*999~
PER*BL**UR*www.anyhealthplan.com/policies.html~
N1*PE*REGIONAL HOPE HOSPITAL*XX*6543210903~
LX*110212~
TS3*6543210903*11*20021231*1*211366.97********138018.4**73348.57~
TS2*2178.45*1919.71**56.82*197.69*4.23~
CLP*666123*1*211366.97*138018.4**MA*1999999444444*11*1~
CAS*CO*45*73348.57~
NM1*QC*1*JONES*SAM*O***HN*666666666A~
MIA*0***138018.4~
DTM*232*20020816~
DTM*233*20020824~
QTY*CA*8~
LX*130212~
TS3*6543210909*13*19961231*1*15000********11980.33**3019.67~
CLP*777777*1*15000*11980.33**MB*1999999444445*13*1~
CAS*CO*45*3019.67~
NM1*QC*1*BORDER*LIZ*E***HN*996669999B~
MOA***MA02~
DTM*232*20020512~
PLB*6543210903*20021231*CV:CP*-1.27~
SE*29*1234~

 

Source

Accredited Standards Committee X12. ASC X12 Standard [Table Data]. Data Interchange Standards Association, Inc., McLean, VA. ASC X12 Examples

HL7 is the registered trademark of Health Level Seven International. X12, chartered by the American National Standards Institute for more than 35 years, develops and maintains EDI standards and XML schemas.

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