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|0001
BPR|I|112357.08|C|ACH|CCP|01|075911603|DA|00000004556640373|1811725341||01|12
TRN|1|001551354|1811725341
REF|EV|1710582184
DTM|405|20220128
N1|PR|COTXIX|XV|7912900843
N3|P.O. BOX 30
N4|DENVER|CO|80201
PER|CX|MEDICAID PROVIDER SERVICES|TE|8442352387
PER|BL|MEDICAID PROVIDER SERVICES|TE|8442352387
N1|PE|TEAM SELECT HOME CARE|XX|1710582184
REF|TJ|611611357
LX|1
CLP|91163953|4|587.2|0||MC|2022024015421
CAS|PI|208|587.2
NM1|QC|1|HART|EARL||||MR|P576096
REF|EA|91163953
DTM|232|20211231
DTM|233|20211231
CLP|91157961|4|2396.68|0||MC|2022024015427
CAS|PI|208|2396.68
NM1|QC|1|LEVERING|EDMUND||||MR|N499248
REF|EA|91157961
DTM|232|20211120
DTM|233|20211201
CLP|91115300|4|1259.72|0||MC|2022024015425
CAS|PI|208|1259.72
NM1|QC|1|MILLER|JODY||||MR|P215665
REF|EA|91115300
DTM|232|20211206
DTM|233|20211210
CLP|359731|1|676.24|541.52||MC|2022026035667|32|2
NM1|QC|1|ANDERSON|GEORGINA||||MR|Q000224
REF|EA|LN200007959101
DTM|232|20220116
DTM|233|20220122
SVC|HC^S9122|90|77.36|0571|2
DTM|472|20220116
CAS|CO|45|12.64
REF|G1|6212660033
REF|6R|5528721387Z1
AMT|B6|77.36
LQ|HE|N381
SVC|HC^S9122|90|77.36|0571|2
DTM|472|20220117
CAS|CO|45|12.64
REF|G1|6212660033
REF|6R|5528721387Z2
AMT|B6|77.36
LQ|HE|N381
SVC|HC^S9122|90|77.36|0571|2
DTM|472|20220118
CAS|CO|45|12.64
REF|G1|6212660033
REF|6R|5528721387Z3
AMT|B6|77.36
LQ|HE|N381
SVC|HC^S9122|90|77.36|0571|2
DTM|472|20220119
CAS|CO|45|12.64
REF|G1|6212660033
REF|6R|5528721387Z4
AMT|B6|77.36
LQ|HE|N381
SVC|HC^S9122|90|77.36|0571|2
DTM|472|20220120
CAS|CO|45|12.64
REF|G1|6212660033
REF|6R|5528721387Z5
AMT|B6|77.36
LQ|HE|N381
SVC|HC^S9122|90|77.36|0571|2
DTM|472|20220121
CAS|CO|45|12.64
REF|G1|6212660033
REF|6R|5528721387Z6
AMT|B6|77.36
LQ|HE|N381
SVC|HC^G0156|23.12|0|0579|0||2
DTM|472|20220121
CAS|PI|15|23.12
REF|6R|5528721387Z7
LQ|HE|M62
SVC|HC^S9122|90|77.36|0571|2
DTM|472|20220122
CAS|CO|45|12.64
REF|G1|6212660033
REF|6R|5528721387Z8
AMT|B6|77.36
LQ|HE|N381
SVC|HC^G0156|23.12|0|0579|0||2
DTM|472|20220122
CAS|PI|15|23.12
REF|6R|5528721387Z9
LQ|HE|M62
CLP|359940|1|1340.92|1163.96||MC|2022026036544
NM1|QC|1|APODACA|KRYSTA||||MR|Y458323
REF|EA|LN200006102401
DTM|232|20220116
DTM|233|20220122
SVC|HC^S9122|180|154.72|0571|4
DTM|472|20220116
CAS|CO|45|25.28
REF|G1|6213230008
REF|6R|5528721423Z1
AMT|B6|154.72
LQ|HE|N381
SVC|HC^G0156|11.56|11.56|0579|1
DTM|472|20220116
REF|G1|6213230008
REF|6R|5528721423Z2
AMT|B6|11.56
SVC|HC^S9122|180|154.72|0571|4
DTM|472|20220117
CAS|CO|45|25.28
REF|G1|6213230008
REF|6R|5528721423Z3
AMT|B6|154.72
LQ|HE|N381
SVC|HC^G0156|11.56|11.56|0579|1
DTM|472|20220117
REF|G1|6213230008
REF|6R|5528721423Z4
AMT|B6|11.56
SVC|HC^S9122|180|154.72|0571|4
DTM|472|20220118
CAS|CO|45|25.28
REF|G1|6213230008
REF|6R|5528721423Z5
AMT|B6|154.72
LQ|HE|N381
SVC|HC^G0156|11.56|11.56|0579|1
DTM|472|20220118
REF|G1|6213230008
REF|6R|5528721423Z6
AMT|B6|11.56
SVC|HC^S9122|180|154.72|0571|4
DTM|472|20220119
CAS|CO|45|25.28
REF|G1|6213230008
REF|6R|5528721423Z7
AMT|B6|154.72
LQ|HE|N381
SVC|HC^G0156|11.56|11.56|0579|1
DTM|472|20220119
REF|G1|6213230008
REF|6R|5528721423Z8
AMT|B6|11.56
SVC|HC^S9122|180|154.72|0571|4
DTM|472|20220120
CAS|CO|45|25.28
REF|G1|6213230008
REF|6R|5528721423Z9
AMT|B6|154.72
LQ|HE|N381
SVC|HC^G0156|11.56|11.56|0579|1
DTM|472|20220120
REF|G1|6213230008
REF|6R|5528721423Z10
AMT|B6|11.56
SVC|HC^S9122|180|154.72|0571|4
DTM|472|20220121
CAS|CO|45|25.28
REF|G1|6213230008
REF|6R|5528721423Z11
AMT|B6|154.72
LQ|HE|N381
SVC|HC^G0156|11.56|11.56|0579|1
DTM|472|20220121
REF|G1|6213230008
REF|6R|5528721423Z12
AMT|B6|11.56
SVC|HC^S9122|180|154.72|0571|4
DTM|472|20220122
CAS|CO|45|25.28
REF|G1|6213230008
REF|6R|5528721423Z13
AMT|B6|154.72
LQ|HE|N381
SVC|HC^G0156|11.56|11.56|0579|1
DTM|472|20220122
REF|G1|6213230008
REF|6R|5528721423Z14
AMT|B6|11.56
CLP|359816|1|710.92|622.44||MC|2022026035978
NM1|QC|1|ARIO|ROD||||MR|O445183
REF|EA|LN200006921401
DTM|232|20220116
DTM|233|20220122
SVC|HC^S9122|90|77.36|0571|2
DTM|472|20220116
CAS|CO|45|12.64
REF|6R|5528721402Z1
AMT|B6|77.36
LQ|HE|N381
SVC|HC^G0156|11.56|11.56|0579|1
DTM|472|20220116
REF|6R|5528721402Z2
AMT|B6|11.56

Solutions:
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