Claims Returned Within The 835 HIPAA Transaction (Summa Care)
Notes that are important to claims processing are as follows:
- 835 Transactions are only generated for claims that have a “paid” or “denied” status. Claims still in the adjudication process or returned with an error messages do not receive an 835 response.
- If a provider submits claims on paper and EDI claims, SummaCare will generate a format compliant 835 Health Care Claim Payment Advice transaction with required elements. However, the content of the resulting 835 will not be as complete as an 835 resulting from an electronic 837 Claim transaction.
- SummaCare will turn off the paper Explanation of Payments (EOP) once a provider starts receiving the 835 transaction. The provider may access Plan Central to review a Portable Document Format (PDF) image of their EOP.