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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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*37189
ViewBPR*I*71677.12*C*ACH*CCP*01*124384877*DA*720000537*1391995276*0000UMR01*01*026013673*DA*4255515319*20200706
ViewTRN*1*544445674*1391995276*0000UMR01
ViewREF*EV*841162789
ViewDTM*405*20200626
ViewN1*PR*UMR
ViewN3*PO BOX 30541
ViewN4*SALT LAKE CITY*UT*841300541
ViewREF*2U*UMR01
ViewPER*CX*UMR EDI TEAM*TE*8005575087
ViewPER*BL*UMR EDI TEAM*EM*UMR-EDI-IT-TEAM_DL@DS.UHC.COM
ViewN1*PE*WESTCHESTER MEDICAL CENTER*XX*1932280666
ViewN3*100 WOODS ROAD
ViewN4*VALHALLA*NY*10595
ViewREF*TJ*133964321
ViewLX*1
ViewCLP*8601716700*22*-26565*0**12*20056379447*13*1
ViewNM1*QC*1*DAVIDSON*PETER
ViewNM1*IL*1*DAVIDSON*PETER****MI*Y19566001
ViewNM1*82*1*PAIS*SHIREEN****XX*1396709838
ViewREF*1L*76413268
ViewSVC*HC:C2625*-414*0*0278
ViewDTM*472*20200218
ViewCAS*PR*96*-414
ViewREF*6R*1
ViewLQ*HE*N130
ViewSVC*HC:88300:59*-160*0*0310
ViewDTM*472*20200218
ViewCAS*PR*96*-160
ViewREF*6R*2
ViewLQ*HE*N130
ViewSVC*HC:88300*-160*0*0310
ViewDTM*472*20200218
ViewCAS*PR*96*-160
ViewREF*6R*3
ViewLQ*HE*N130
ViewSVC*HC:43266*-24882*0*0360
ViewDTM*472*20200218
ViewCAS*PR*96*-24882
ViewREF*6R*4
ViewLQ*HE*N130
ViewSVC*NU:0370*-949*0
ViewDTM*472*20200218
ViewCAS*PR*96*-949
ViewREF*6R*5
ViewLQ*HE*N130
ViewLX*2
ViewCLP*8601716700*1*26565*6464.9*30*12*20056379447*13*1
ViewNM1*QC*1*DAVIDSON*PETER
ViewNM1*IL*1*DAVIDSON*PETER****MI*Y19566001
ViewNM1*82*1*PAIS*SHIREEN****XX*1396709838
ViewREF*1L*76413268
ViewAMT*AU*26565
ViewSVC*HC:C2625*414*114.9*0278
ViewDTM*472*20200218
ViewCAS*CO*45*269.1
ViewCAS*PR*3*30
ViewREF*6R*EI022520204391831-01
ViewAMT*B6*144.9
ViewSVC*HC:88300:59*160*38.85*0310
ViewDTM*472*20200218
ViewCAS*CO*45*121.15
ViewREF*6R*EI022520204391831-02
ViewAMT*B6*38.85
ViewSVC*HC:88300*160*38.85*0310
ViewDTM*472*20200218
ViewCAS*CO*45*121.15
ViewREF*6R*EI022520204391831-03
ViewAMT*B6*38.85
ViewSVC*HC:43266*24882*6041.86*0360
ViewDTM*472*20200218
ViewCAS*CO*45*18840.14
ViewREF*6R*EI022520204391831-04
ViewAMT*B6*6041.86
ViewSVC*NU:0370*949*230.44
ViewDTM*472*20200218
ViewCAS*CO*45*718.56
ViewREF*6R*EI022520204391831-05
ViewAMT*B6*230.44
ViewLX*3
ViewCLP*8657341700*1*300*84.26**12*20162113902*14*1
ViewNM1*QC*1*GOULD*JOHNATHAN
ViewNM1*IL*1*GOULD*JOHNATHAN****MI*Y19567068
ViewNM1*82*1*KAR*KAUSIK****XX*1467646448
ViewREF*1L*76413268
ViewAMT*AU*300
ViewSVC*HC:86769*300*84.26*0302
ViewDTM*472*20200504
ViewCAS*CO*45*215.74
ViewREF*6R*EI051120233271495-01
ViewAMT*B6*84.26
ViewLX*4
ViewCLP*8657130400*1*300*84.26**12*20162113908*14*1
ViewNM1*QC*1*NALBANDIAN*ALAN
ViewNM1*IL*1*NALBANDIAN*ALAN****MI*Y19568471
ViewNM1*82*1*KAR*KAUSIK****XX*1467646448
ViewREF*1L*76413268
ViewAMT*AU*300
ViewSVC*HC:86769*300*84.26*0302
ViewDTM*472*20200504
ViewCAS*CO*45*215.74
ViewREF*6R*EI051120233271496-01
ViewAMT*B6*84.26
ViewLX*5
ViewCLP*8656380600*1*150*42.13**12*20162113917*13*1
ViewNM1*QC*1*DEVLIN*EDWARD
ViewNM1*IL*1*DEVLIN*EDWARD****MI*Y19561822
ViewNM1*82*1*KAR*KAUSIK****XX*1467646448
ViewREF*1L*76413268
ViewAMT*AU*150
ViewSVC*HC:86769*150*42.13*0302
ViewDTM*472*20200501
ViewCAS*CO*45*107.87
ViewREF*6R*EI051220236831446-01
ViewAMT*B6*42.13
ViewLX*6
ViewCLP*8657045400*1*300*84.26**12*20162113922*13*1
ViewNM1*QC*1*DIAZ*JULIO
ViewNM1*IL*1*DIAZ*JULIO****MI*Y19560591
ViewNM1*82*1*KAR*KAUSIK****XX*1467646448
ViewREF*1L*76413268
ViewAMT*AU*300
ViewSVC*HC:86769*300*84.26*0302
ViewDTM*472*20200504
ViewCAS*CO*45*215.74
ViewREF*6R*EI051220236831447-01
ViewAMT*B6*84.26
ViewLX*7
ViewCLP*8656848200*1*150*42.13**12*20162113927*13*1
ViewNM1*QC*1*DONOVAN*FRANK
ViewNM1*IL*1*DONOVAN*FRANK****MI*Y19563561
ViewNM1*82*1*KAR*KAUSIK****XX*1467646448
ViewREF*1L*76413268
ViewAMT*AU*150
ViewSVC*HC:86769*150*42.13*0302
ViewDTM*472*20200505
ViewCAS*CO*45*107.87
ViewREF*6R*EI051220236831449-01
ViewAMT*B6*42.13
ViewLX*8
ViewCLP*8657229400*1*300*84.26**12*20162113932*13*1
ViewNM1*QC*1*RAO*ANTHONY
ViewNM1*IL*1*RAO*ANTHONY****MI*Y19561884
ViewNM1*82*1*KAR*KAUSIK****XX*1467646448
ViewREF*1L*76413268
ViewAMT*AU*300
ViewSVC*HC:86769*300*84.26*0302
ViewDTM*472*20200504
ViewCAS*CO*45*215.74
ViewREF*6R*EI051220236831523-01
ViewAMT*B6*84.26
ViewLX*9
ViewCLP*8657913300*1*150*42.13**12*20162113933*13*1
ViewNM1*QC*1*DUANY*WILLIAM
ViewNM1*IL*1*DUANY*WILLIAM****MI*Y19564382
ViewNM1*82*1*KAR*KAUSIK****XX*1467646448
ViewREF*1L*76413268
ViewAMT*AU*150
ViewSVC*HC:86769*150*42.13*0302
ViewDTM*472*20200505
ViewCAS*CO*45*107.87
ViewREF*6R*EI051220236831450-01
ViewAMT*B6*42.13
ViewLX*10
ViewCLP*8656986000*1*150*42.13**12*20162113938*13*1
ViewNM1*QC*1*RAUSO*JERARD
ViewNM1*IL*1*RAUSO*JERARD****MI*Y19563489
ViewNM1*82*1*KAR*KAUSIK****XX*1467646448
ViewREF*1L*76413268
ViewAMT*AU*150
ViewSVC*HC:86769*150*42.13*0302
ViewDTM*472*20200504
ViewCAS*CO*45*107.87
ViewREF*6R*EI051220236831524-01
ViewAMT*B6*42.13
ViewLX*11
ViewCLP*8656409300*1*150*42.13**12*20162113940*13*1
ViewNM1*QC*1*DWYER*ANDREW
ViewNM1*IL*1*DWYER*ANDREW****MI*Y19561895
ViewNM1*82*1*KAR*KAUSIK****XX*1467646448
ViewREF*1L*76413268
ViewAMT*AU*150
ViewSVC*HC:86769*150*42.13*0302
ViewDTM*472*20200501
ViewCAS*CO*45*107.87
ViewREF*6R*EI051220236831451-01
ViewAMT*B6*42.13
ViewLX*12
ViewCLP*8656947200*1*300*84.26**12*20162113946*13*1
ViewNM1*QC*1*REICH*EDWARD
ViewNM1*IL*1*REICH*EDWARD****MI*Y19566617
ViewNM1*82*1*KAR*KAUSIK****XX*1467646448
ViewREF*1L*76413268
ViewAMT*AU*300
ViewSVC*HC:86769*300*84.26*0302
ViewDTM*472*20200504
ViewCAS*CO*45*215.74
ViewREF*6R*EI051220236831525-01
ViewAMT*B6*84.26

Solutions:
Are you looking to trade the EDI 835 transaction with one of your trading partners? Do you need an EDI VAN Savings solution to exchange the 835? Or perhaps you would like to use a Cloud-Based application, so you can plug your 835 transaction directly into your ERP and TMS systems. Even small companies have the ability to trade the EDI 835 by using the EDI Mobile Device solution.
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