Update: 2023-03-08
835 - Claim Payment/Advise
Important
Bishop's X12 NET SDK adheres to the 835 Claim Payment/Advise for Healthcare Insurance (April 2006) defined in the ASC X12N/005010X2221, Version 5, Release 1, ASC X12 Standards for Electronic Data Interchange, Technical Report Type 3 Implementation Guide.
Please obtain and reference this implementation guide for a detailed explanation of the 835 transaction set and to understand how it defines uniform data content, identifies valid code tables and specifies values applicable for the business focus of the 835.
The 835 contains information about the payee, the payer, the amount, and any identifying information about of the payment. It can authorize a payee to have a DFI take funds from the payer's account and transfer those funds to the payee's account. If the 835 is used to authorize a DFI to move funds the 835 is sent to the payer's DFI.
The 835 includes information about the payer's account; the payee's DFI, account, and timing; and the method and amount of the funds transfer. This process is known as an "Electronic Funds Transfer" (EFT). The result of an EFT is that funds are deposited directly into the payee's account. The remittance information may or may not have been transmitted to and through the banking network.
One 835 transaction set reflects a single payment device. In other words, one 835 corresponds to one check or one EFT payment. Multiple bills can be referenced within a single 835.
This SDK is designed to assist those who send and/or receive Electronic Remittance Advice (ERA) and/or payments in the 835 format. Entities receiving the 835 include, but are not limited to, hospitals, nursing homes, laboratories, physicians, dentists, and allied professional groups. All of these entities are referred to as payees or providers within this document.
Organizations sending the 835 include insurance companies, Third Party Administrators (TPAs), service corporations, state and federal agencies and their contractors, plan purchasers, and any other entities that process health care reimbursements. Other business partners affiliated with the 835 include Depository Financial Institutions (DFIs), billing services, consulting services, vendors of systems, software and EDI translators, EDI network intermediaries such as Automated Clearing Houses, value-added networks, and telecommunication services.
Creating the 835 from scratch
[TODO]
Splitting the 835 into Individual Transactions
835's are split by Payment advise .
Batching Transactions
Batching transactions is the process of combining multiple individual X12 transactions into one or more consolidated transactions.
- Must create a new BHT Segment
- Transactions:
- may be placed into a group with the same Reference Code
- will be placed into individual groups when reference code is unique
- may be combined by Billing provider if
- will be combined by billing provider's ETIN
- may be combined by payer
- may be combined by patient
- may be placed into a group with the same Reference Code
- SetReceiver
Note
837 Notes
Claim detail (L2300) is positioned in the hierarchical level that defines its owner-participant. When the Patient is the Subscriber the Claim detail is placed following loop 2010BB in the Subscriber hierarchical. When the Patient is not the Subscriber, the Claim detail is placed at the Patient hierarchical level.