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

SegmentEntire Segment
ViewST*835*07504123
ViewBPR*H*5.75*C*NON************20110315
ViewTRN*1*A04B001017.07504*1346000128
ViewDTM*405*20110308
ViewN1*PR*ASHTABULA COUNTY ADAMH BD*XX*6457839886
ViewN3*4817 STATE ROAD SUITE 203
ViewN4*ASHTABULA*OH*44004
ViewN1*PE*LAKE AREA RECOVERY CENTER *FI*346608640
ViewN3*2801 C. COURT
ViewN4*ASHTABULA*OH*44004
ViewREF*PQ*1017
ViewLX*1
ViewCLP*444444*1*56.70*56.52*0*MC*0000000655555555*53
ViewNM1*QC*1*FUDD*ELMER*S***MI*1333333
ViewNM1*82*2*WECOVERWY SVCS*****FI*346608640
ViewREF*F8*A76B04054
ViewSVC*HC:H0005:HF:H9*56.70*56.52**6
ViewDTM*472*20110205
ViewCAS*CO*42*0.18*0
ViewREF*6R*444444
ViewCLP*999999*4*25.95*0*25.95*13*0000000555555555*11
ViewNM1*QC*1*SAM*YOSEMITE*A***MI*3333333
ViewNM1*82*2*ACME AGENCY*****FI*310626223
ViewREF*F8*H57B10401
ViewSVC*ZZ:M2200:HE*25.95*0**1
ViewDTM*472*20021224
ViewCAS*CR*18*25.95*0
ViewCAS*CO*42*0*0
ViewREF*6R*999999
ViewCLP*888888*4*162.13*0*162.13*MC*0000000456789123*11
ViewNM1*QC*1*SQUAREPANTS*BOB* ***MI*2222222
ViewNM1*82*2*BIKINI AGENCY*****FI*310626223
ViewREF*F8*H57B10401
ViewSVC*ZZ:M151000:F0*162.13*0**1.9
ViewDTM*472*20020920
ViewCAS*CO*29*162.13*0*42*0*0
ViewREF*6R*888888
ViewCLP*111111*2*56.52*18.88*0*13*0000000644444444*53
ViewNM1*QC*1*LEGHORN*FOGHORN*P***MI*7777777
ViewNM1*82*2*CHICKENHAWK SVCS*****FI*346608640
ViewREF*F8*A76B04054
ViewSVC*HC:H0005:HF:H9*56.52*18.88**6
ViewDTM*472*20031209
ViewCAS*CO*42*0*0
ViewCAS*OA*23*37.64*0
ViewREF*6R*111111
ViewCLP*121212*4*56.52*0*0*13*0000000646464640*53
ViewNM1*QC*1*EXPLORER*DORA****MI*1717171
ViewNM1*82*2*SWIPER AGENCY*****FI*346608640
ViewREF*F8*A76B04054
ViewSVC*HC:H0005:HF:H9*56.52*0**6
ViewDTM*472*20031202
ViewCAS*CO*42*0*0
ViewCAS*OA*23*57.6*0*23*-1.08*0
ViewREF*6R*121212
ViewCLP*333333*1*74.61*59.69*14.92*13*0000000688888888*55
ViewNM1*QC*1*BEAR*YOGI* ***MI*2222222
ViewNM1*82*2*JELLYSTONE SVCS*****FI*346608640
ViewREF*F8*A76B04054
ViewSVC*ZZ:A0230:HF*74.61*59.69**1
ViewDTM*472*20110203
ViewCAS*PR*2*14.92*0
ViewCAS*CO*42*0*0
ViewREF*6R*333333
ViewCLP*777777*25*136.9*0*0*13*0000000622222222*53
ViewNM1*QC*1*BIRD*TWEETY*M***MI*4444444
ViewNM1*82*2*GRANNY AGENCY*****FI*340716747
ViewREF*F8*A76B03293
ViewSVC*HC:H0015:HF:99:H9*136.9*0**1
ViewDTM*472*20030911
ViewCAS*PI*104*136.72*0
ViewCAS*CO*42*0.18*0
ViewREF*6R*777777
ViewCLP*123456*22*-42.58*-42.58*0*13*0000000657575757*11
ViewNM1*QC*1*SIMPSON*HOMER* ***MI*8787888
ViewNM1*82*2*DOH GROUP*****FI*310626223
ViewREF*F8*A57B04033
ViewSVC*HC:H0036:GT:UK*-42.58*-42.58**-2
ViewDTM*472*20110102
ViewCAS*CR*141*0*0*42*0*0*22*0*0
ViewCAS*OA*141*0*0
ViewREF*6R*123456
ViewCLP*090909*22*-86.76*-86.76*0*MC*0000000648484848*53
ViewNM1*QC*1*DUCK*DAFFY*W***MI*1245849
ViewNM1*82*2*ABTHSOLUTE HELP*****FI*346608640
ViewREF*F8*A76B04054
ViewSVC*HC:H0004:HF:H9*-86.76*-86.76**-4
ViewDTM*472*20110210
ViewCAS*CR*22*0*0*42*0*0
ViewCAS*OA*22*0*0
ViewREF*6R*090909
ViewLQ*HE*MA92
ViewSE*93*07504123

Solutions:
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