Sample EDI 835 Data for the Health Care Claim Payment/Advice Transaction Set


AgencySet IDFGTransaction DescriptionSubcommittee
ANSI835HPHealth Care Claim Payment/Advice Insurance


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Research and Development:
Below is a sample EDI 835 transaction set. The Jobisez.com site has an online translation tool that converts the EDI 835 (Health Care Claim Payment/Advice) document into a CSV file. If you are researching the 835s, you can view other trading partner's mapping specifications. You can also gain knowledge by researching all EDI document types. Jobisez LLC can also provide assistance if you need additional help.

Sample of an EDI 835 Transaction Set

ST*835*0001
BPR*I*1426.96*C*ACH*CCP*01*000000000000*DA*00000000000000000*1610600439**01*231372691*DA*7675327691*20180906
TRN*1*E06565609*1610600439
DTM*405*20180831
N1*PR*KY MEDICAID
N3*275 E. Main St*6W - C
N4*Frankfort*KY*406210001
PER*CX*Provider Relations Department*TE*8008071232*TE*5025648217*EX*Ky_provider_inquiry@hp.com
PER*BL**EM*KY_EDI_Helpdesk@hp.com*TE*800.205.4696
N1*PE*ACTIVE DAY HOME CARE*XX*1558400978
REF*TJ*203220889
LX*1
CLP*D000037M-8668*1*109.50*109.50**MC*0024416891
NM1*QC*1*McIntosh*Darlene****MR*0028147361
NM1*82*2*ACTIVE DAY HOME CARE*****XX*1558400978
DTM*232*20181015
DTM*233*20181021
SVC*HC:S5108*18.0*18.0**12
DTM*472*20181015
REF*HPI*1497894935
AMT*B6*18.0
SVC*HC:S5108*13.5*13.5**9
DTM*472*20181016
REF*HPI*1497894935
AMT*B6*13.5
SVC*HC:S5108*21.0*21.0**14
DTM*472*20181017
REF*HPI*1497894935
AMT*B6*21.0
SVC*HC:S5108*16.5*16.5**11
DTM*472*20181018
REF*HPI*1497894935
AMT*B6*16.5
SVC*HC:S5108*13.5*13.5**9
DTM*472*20181019
REF*HPI*1497894935
AMT*B6*13.5
SVC*HC:S5108*12.0*12.0**8
DTM*472*20181020
REF*HPI*1497894935
AMT*B6*12.0
SVC*HC:S5108*15.0*15.0**10
DTM*472*20181021
REF*HPI*1497894935
AMT*B6*15.0
SE*43*183220828

Solutions:
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