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

Entire Segment
ST*835*5200
BPR*I*5520.27*C*ACH*CCP*01*124384877*DA*720000526*1204581265*0000VACCN*01*303
TRN*1*3000481771*1204581265*0000VACCN
REF*EV*841162764
REF*F2*1871095885 R34010315004727
DTM*405*20210315
N1*PR*OPTUM VA CCN REGION 3
N3*OPTUM SHARED SERVICE ACCOUNTING*3160 FAIRVIEW PARK DR SUITE 600
N4*FALLS CHURCH*VA*220424516
REF*2U*VACCN
PER*CX*CCN PROVIDER SERVICES*TE*8889017407
PER*BL*CCN PROVIDER SERVICES*TE*8889017407
PER*IC**UR*WWW.VACOMMUNITYCARE.COM
N1*PE*HARMONY HOME HEALTH LLC*XX*1871095885
N3*240 E APACHE ST
N4*TULSA*OK*74127
REF*TJ*824664774
LX*1
CLP*201*1*1200*955.92**VA*H063X16GH0000*12*1
NM1*QC*1*JUSTUS*TONIE*M***MI*1001273339V775363
REF*EA*10
DTM*050*20210304
AMT*AU*955.92
SVC*HC:G0156*240*238.98**16
DTM*472*20210222
CAS*CO*45*1.02
REF*6R*H063X16GH00000001
AMT*B6*238.98
SVC*HC:G0156*240*238.98**16
DTM*472*20210223
CAS*CO*45*1.02
REF*6R*H063X16GH00000002
AMT*B6*238.98
SVC*HC:G0156*240*238.98**16
DTM*472*20210224
CAS*CO*45*1.02
REF*6R*H063X16GH00000003
AMT*B6*238.98
SVC*HC:G0156*240*238.98**16
DTM*472*20210225
CAS*CO*45*1.02
REF*6R*H063X16GH00000004
AMT*B6*238.98
SVC*HC:G0156*240*0**16
DTM*472*20210226
CAS*CO*96*240
REF*6R*H063X16GH00000005
LQ*HE*N640
LX*2
CLP*241*1*1680*1672.84**VA*H069X46WW0000*12*1
NM1*QC*1*HISHAW*RONALD*L***MI*1002753232V433505
REF*EA*7
DTM*050*20210310
AMT*AU*1672.84
SVC*HC:G0156*420*418.21**28
DTM*472*20210301
CAS*CO*45*1.79
REF*6R*H069X46WW00000001
AMT*B6*418.21
SVC*HC:G0156*420*418.21**28
DTM*472*20210302
CAS*CO*45*1.79
REF*6R*H069X46WW00000002
AMT*B6*418.21
SVC*HC:G0156*420*418.21**28
DTM*472*20210303
CAS*CO*45*1.79
REF*6R*H069X46WW00000003
AMT*B6*418.21
SVC*HC:G0156*420*418.21**28
DTM*472*20210304
CAS*CO*45*1.79
REF*6R*H069X46WW00000004
AMT*B6*418.21
LX*3
CLP*246*1*810*806.53**VA*H069X46XP0000*12*1
NM1*QC*1*LUCAS*JOE*E***MI*1014863142V420789
REF*EA*23
DTM*050*20210310
AMT*AU*806.53
SVC*HC:G0156*180*179.23**12
DTM*472*20210301
CAS*CO*45*.77
REF*6R*H069X46XP00000001
AMT*B6*179.23
SVC*HC:G0156*210*209.1**14
DTM*472*20210302
CAS*CO*45*.9
REF*6R*H069X46XP00000002
AMT*B6*209.1
SVC*HC:G0156*210*209.1**14
DTM*472*20210303
CAS*CO*45*.9
REF*6R*H069X46XP00000003
AMT*B6*209.1
SVC*HC:G0156*210*209.1**14
DTM*472*20210304
CAS*CO*45*.9
REF*6R*H069X46XP00000004
AMT*B6*209.1
LX*4
CLP*250*1*540*537.7**VA*H069X46YB0000*12*1
NM1*QC*1*WALKER*WILLIAM*D***MI*1005334506V076124
REF*EA*32
DTM*050*20210310
AMT*AU*537.7
SVC*HC:G0156*240*238.98**16
DTM*472*20210301
CAS*CO*45*1.02
REF*6R*H069X46YB00000001
AMT*B6*238.98
SVC*HC:G0156*300*298.72**20
DTM*472*20210302
CAS*CO*45*1.28
REF*6R*H069X46YB00000002
AMT*B6*298.72
LX*5
CLP*248*1*240*238.98**VA*H069X46YR0000*12*1
NM1*QC*1*RIDDLE*MARCUS*A***MI*1004179950V617864
REF*EA*22
DTM*050*20210310
AMT*AU*238.98
SVC*HC:G0156*240*238.98**16
DTM*472*20210303
CAS*CO*45*1.02
REF*6R*H069X46YR00000001
AMT*B6*238.98
LX*6
CLP*253*1*165*164.3**VA*H069X46YT0000*12*1
NM1*QC*1*RIDDLE*MARCUS*A***MI*1004179950V617864
REF*EA*22
DTM*050*20210310
AMT*AU*164.3
SVC*HC:G0156*165*164.3**11
DTM*472*20210301
CAS*CO*45*.7
REF*6R*H069X46YT00000001
AMT*B6*164.3
LX*7
CLP*180*1*128*128**VA*H070X3CJV0000*12*1
NM1*QC*1*HUBBARD*CLAUDE*F***MI*1015347084V535618
REF*EA*9
DTM*050*20210311
AMT*AU*128
SVC*HC:G0156*128*128**16
DTM*472*20210219
REF*6R*H070X3CJV00000001
AMT*B6*128
LX*8
CLP*183*1*104*104**VA*H070X3CJX0000*12*1
NM1*QC*1*LONGACRE*CHARLES****MI*1009386010V366642
REF*EA*94
DTM*050*20210311
AMT*AU*104
SVC*HC:G0156*104*104**13
DTM*472*20210215
REF*6R*H070X3CJX00000001
AMT*B6*104
LX*9
CLP*179*1*912*912**VA*H070X3CKF0000*12*1
NM1*QC*1*HISHAW*RONALD*L***MI*1002753232V433505
REF*EA*7
DTM*050*20210311
AMT*AU*912
SVC*HC:G0156*232*232**29
DTM*472*20210215
REF*6R*H070X3CKF00000001
AMT*B6*232
SVC*HC:G0156*232*232**29
DTM*472*20210216
REF*6R*H070X3CKF00000002
AMT*B6*232
SVC*HC:G0156*224*224**28
DTM*472*20210217
REF*6R*H070X3CKF00000003
AMT*B6*224
SVC*HC:G0156*224*224**28
DTM*472*20210218
REF*6R*H070X3CKF00000004
AMT*B6*224
SE*181*5200

Solutions:
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