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*07504123
BPR*H*5.75*C*NON************20110315
TRN*1*A04B001017.07504*1346000128
DTM*405*20110308
N1*PR*ASHTABULA COUNTY ADAMH BD*XX*6457839886
N3*4817 STATE ROAD SUITE 203
N4*ASHTABULA*OH*44004
N1*PE*LAKE AREA RECOVERY CENTER *FI*346608640
N3*2801 C. COURT
N4*ASHTABULA*OH*44004
REF*PQ*1017
LX*1
CLP*444444*1*56.70*56.52*0*MC*0000000655555555*53
NM1*QC*1*FUDD*ELMER*S***MI*1333333
NM1*82*2*WECOVERWY SVCS*****FI*346608640
REF*F8*A76B04054
SVC*HC:H0005:HF:H9*56.70*56.52**6
DTM*472*20110205
CAS*CO*42*0.18*0
REF*6R*444444
CLP*999999*4*25.95*0*25.95*13*0000000555555555*11
NM1*QC*1*SAM*YOSEMITE*A***MI*3333333
NM1*82*2*ACME AGENCY*****FI*310626223
REF*F8*H57B10401
SVC*ZZ:M2200:HE*25.95*0**1
DTM*472*20021224
CAS*CR*18*25.95*0
CAS*CO*42*0*0
REF*6R*999999
CLP*888888*4*162.13*0*162.13*MC*0000000456789123*11
NM1*QC*1*SQUAREPANTS*BOB* ***MI*2222222
NM1*82*2*BIKINI AGENCY*****FI*310626223
REF*F8*H57B10401
SVC*ZZ:M151000:F0*162.13*0**1.9
DTM*472*20020920
CAS*CO*29*162.13*0*42*0*0
REF*6R*888888
CLP*111111*2*56.52*18.88*0*13*0000000644444444*53
NM1*QC*1*LEGHORN*FOGHORN*P***MI*7777777
NM1*82*2*CHICKENHAWK SVCS*****FI*346608640
REF*F8*A76B04054
SVC*HC:H0005:HF:H9*56.52*18.88**6
DTM*472*20031209
CAS*CO*42*0*0
CAS*OA*23*37.64*0
REF*6R*111111
CLP*121212*4*56.52*0*0*13*0000000646464640*53
NM1*QC*1*EXPLORER*DORA****MI*1717171
NM1*82*2*SWIPER AGENCY*****FI*346608640
REF*F8*A76B04054
SVC*HC:H0005:HF:H9*56.52*0**6
DTM*472*20031202
CAS*CO*42*0*0
CAS*OA*23*57.6*0*23*-1.08*0
REF*6R*121212
CLP*333333*1*74.61*59.69*14.92*13*0000000688888888*55
NM1*QC*1*BEAR*YOGI* ***MI*2222222
NM1*82*2*JELLYSTONE SVCS*****FI*346608640
REF*F8*A76B04054
SVC*ZZ:A0230:HF*74.61*59.69**1
DTM*472*20110203
CAS*PR*2*14.92*0
CAS*CO*42*0*0
REF*6R*333333
CLP*777777*25*136.9*0*0*13*0000000622222222*53
NM1*QC*1*BIRD*TWEETY*M***MI*4444444
NM1*82*2*GRANNY AGENCY*****FI*340716747
REF*F8*A76B03293
SVC*HC:H0015:HF:99:H9*136.9*0**1
DTM*472*20030911
CAS*PI*104*136.72*0
CAS*CO*42*0.18*0
REF*6R*777777
CLP*123456*22*-42.58*-42.58*0*13*0000000657575757*11
NM1*QC*1*SIMPSON*HOMER* ***MI*8787888
NM1*82*2*DOH GROUP*****FI*310626223
REF*F8*A57B04033
SVC*HC:H0036:GT:UK*-42.58*-42.58**-2
DTM*472*20110102
CAS*CR*141*0*0*42*0*0*22*0*0
CAS*OA*141*0*0
REF*6R*123456
CLP*090909*22*-86.76*-86.76*0*MC*0000000648484848*53
NM1*QC*1*DUCK*DAFFY*W***MI*1245849
NM1*82*2*ABTHSOLUTE HELP*****FI*346608640
REF*F8*A76B04054
SVC*HC:H0004:HF:H9*-86.76*-86.76**-4
DTM*472*20110210
CAS*CR*22*0*0*42*0*0
CAS*OA*22*0*0
REF*6R*090909
LQ*HE*MA92
SE*93*07504123

Solutions:
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