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The Health Care Claim Payment/Advice (835) transaction set is designed for the
payment of claims and transfer of remittance information of the Health Care Industry. The
transaction set can be used to make a payment, send an Explanation of Benefit (EOB)
remittance service, or make a payment and send an EOB remittance and advice from a health
care payer to health care provider, or their agent, either directly or through a
depository financial institution. As such, the transaction is divided into these
sections.
Table 1: Opens the transaction, provides payment information and identifies payer
and
payee.
Table 2: Provides claim
and service-specific remittance data.
Table 3: Provides payee-specific adjustment data and ends the transaction.
Note:
The 835 is used to transmit payment and data needed for the posting by a provider
subsequent to the adjudication of a claim. Non-adjudication claim information should be
carried in a Health Care Claim Status Notification (277) transaction.
Balancing
The amounts reported in the 835, if present, must balance at three different
levels: the service line, the claim, and the transaction. Adjustments within the
835, at the Claim Adjustment Segment (CAS) or PLB segments, decrease the payment
when the adjustment amount is positive, and increase the payment when
the adjustment is negative.
Service Line Balancing
While the SVC loop is optional, if present, it must balance,
so that the submitted service charge minus the sum of all monetary adjustments
equals the amount paid for this
service line, i.e.,
SVC02 - (sum of ALL 02-090(CAS03/06/09/12/15/18)) = SVC03
where:
SVC02 is the submitted charge for this service.
SVC03 is the paid amount for this service.
02-090(CAS03/06/09/12/15/18) - The fields
in the parentheses are the monetary adjustment amounts
applied to this service. 02-090 refers to Table 2, segment position 090.
Claim balancing
With each CLP loop, balancing must occur so that the submitted charges for the
claim minus the sum of all monetary adjustments equals the claim paid amount.
When the SVC loop is not present:
CLP03 - (sum of ALL 02-020(CAS03/06/09/12/15/18)) = CLP04
where:
02-020(CAS03/06/09/12/15/18) - The fields
in the parentheses are the monetary adjustment amounts
applied to this claim. 02-020 refers to Table 2, segment position 020.
When the SVC loop is present:
CLP03 - (sum of ALL 02-090(CAS03/06/09/12/15/18)) = CLP04
where:
02-090(CAS03/06/09/12/15/18) - The fields
in the parentheses are the monetary adjustment amounts
applied to this claim in the CAS segments, which are found at Table 2 position 020 (Claim level) and
Table 2 position 090 (Service level).
Transaction Balancing
Within the transaction, the sum of all the claim payments minus the sum of all
provider level adjustments must equal the total payment amount.
sum of ALL CLP04 - sum of ALL PLB04/06/08/10/12/14 = BRP02
where:
BRP02 is the total payment amount of this 835.
Sum of ALL CLP04 is the total of all claim payments included in this
835.
PLB04/06/08/10/12/14 is the provider level adjustments made to the
claim payments.
Data Relationship between
835 and 837
One 835 transaction can account for claims submitted using multiple 837
transactions. The Claim Submitter's Identifier reported in the claim within the 837 is
returned in the 835 transaction for tracking purposes. The Claim Submitter's Identifier is
located in the 837 in segment CLP, position 01. In the 835, the Claim Submitter's
Identifier is in segment CLP, position 01.
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