835 EDI Transaction  implementation instructions and guides

835 EDI Transaction835 EDI Transaction means Health Care Claim Payment/Advice Transaction that allows providers to receive claim remittance information electronically. The ASC X12N 835 (005010X221 and 005010X221A1) 835 EDI Transaction Set Technical Report Type 3 and errata have been established as the standard for claim remittance transaction compliance.

The Tufts Health Plan 835 Claim Payment/Advice Transaction is based on the National Electronic Data Interchange Transaction Set Technical Report Type 3: Health Care Claim Payment/Advice ASC X12N 835 (005010X221 & 005010X221A1) – also known as the Implementation Guide.

Payer Specific Business Rules and Limitations

  • All NPIs must be registered with the Provider Information Department prior to transmission
  • Receivers must go through the appropriate set-up/authorization process in order to receive the 835 ERA
  • The 835 Claim Payment/Advice Transaction contains paid and denied claim data on both electronic and paper claims for all Tufts Health Plan products, including Tufts Health Plan Medicare Preferred products
  • Separate files will be received for both Commercial and Tufts Health Plan Medicare Preferred products
  • The 835 EDI Transaction will contain Remittance Information only. Tufts Health Plan does not conduct Electronic Fund Transfers at this time
  • Tufts Health Plan will not be creating an 835 transaction for settlement and capitation checks
  • The 835 EDI Transaction is available to receivers for all Tufts Health Plan products, including Tufts Health Plan Medicare Preferred products on a weekly basis. All files are deleted after 7 days from the OUT mailbox
  • The selection of claims for the 835 transaction is based on the pay date. For new receivers requesting our 835 Claim Payment/Advice Transaction, it will be created for the first check run following the receiver’s go-live date. No previous 835 transactions will be created
  • Existing receivers of the 835 Transaction can request a previous 835 transaction set, available for pickup again, for up to 8 weeks by contacting EDI Operations
  • Tufts Health Plan’s paper Statements of Account (SOA) for HMO, POS, PPO and Tufts Health Plan Medicare Preferred has not changed; therefore there will be differences between the paper SOAs and 835 Transactions. However, the payment amounts should always be the same between the related paper SOA and 835 Transaction. Due to HIPAA regulations, our proprietary Message, Reason and Adjustment Codes, found on your paper SOA, cannot be sent on the 835 Transaction. These proprietary codes have been translated to HIPAA compliant codes for the 835 Transaction. It is important to note that your paper SOA will continue to reflect Tufts Health Plan specific codes, whereas your 835 Transaction will reflect the new HIPAA codes
  • Tufts Health Plan will continue with the current policy for paper claim corrections for HMO, POS, PPO and Tufts Health Plan Medicare Preferred. A copy of your paper SOA and necessary documentation must be submitted with paper claim corrections. Do not send a paper copy of the Tufts Health Plan 835 Transaction in place of the SOA.
  • All Loops, Segments and Data Elements required and conditionally required by the 835 Transaction Set Technical Report Type 3 will generally be sent if the original claim was submitted via an 837 Transaction. However, some Segments & Data Elements conditionally required will not be sent back on the 835 when:
    • The original claim was submitted on paper
    • Claim required intervention for processing.
  • The 835 Technical Report Type 3 requires payers to categorize financial adjustments to claims into HIPAA Claim Adjustment Group Codes.

Setup Process

Providers interested in receiving 835 electronic remittance advice should contact EDI Operations via email or telephone to request setup. EDI Operations will set up a username and password for new receivers. Current 837 Submitters will use their current username/password setups to receive the 835 Transaction. Upon completion of the setup, EDI Operations will send a confirmation email to confirm the username/password and GO LIVE date.

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