HIPAA EDI 835 transaction and balancing formula description
The HIPAA EDI 835 example given in the post is for two institutional claims. It is a remittance advice and it’s submitted by BCBS DISNEY (payer) to UCLA MEDICAL CENTER (payee). BPR-01 = “I” which means “Remittance Advice Only” The payment is for patient Mickey Mouse and Donald Duck with claim numbers ABC9001 and ABC9002. Each claim of this HIPAA EDI 835 example was for the amount of $225. However, a For Mickey Mouse the Patient Responsibility amount of $5 exists and Contractual Adjustment of $20 exists so the payment amount is $200. For Donald Duck’s claim the Patient Responsibility amount of $10 exists and Contractual Adjustment of $20 exists so the payment amount is $195. With Mickey’s and Donald’s claim the total payment amount is $395. However, BCBS Disney paid this HIPAA EDI 835 claim off very early and they are entitled to an Early Payment Allowance of 1% of the total payment which in this case is $3.95. Therefore the remit to payment amount in BPR02 is 391.05.
HIPAA EDI 835 example
ST*835*112233*005010X221A1
BPR*I*391.05*C*ACH*CCP*01*322271724*DA*203158175*8076853391**01*122000496*DA*7341099666*20120131
TRN*1*051036622050010*1262721578
N1*PR*BCBS DISNEY
N3*POBLADO RD
N4*LOS ANGELES*CA*9006
PER*BL*MICHAEL EISNER*TE*7145205060*EX*123*EM*edi@bcbsdisney.com
PER*IC**UR*www.bcbsdisney.com/policies.html
N1*PE*UCLA MEDICAL CENTER*XX*1215193883
LX*1001
CLP*ABC9001*1*225*200*5*12*1142381711242*22*1
CAS*CO*45*20
NM1*QC*1*MOUSE*MICKEY****MI*60345914A
SVC*HC:98765*150*145
DTM*472*20120124
CAS*PR*3*5
REF*0K*8910
SVC*HC:26591*75*75
DTM*472*20120124
LX*1002
CLP*ABC9002*1*225*195*10*12*1142381711242*22*1
CAS*CO*45*20
NM1*QC*1*DUCK*DONALD****MI*60345914B
SVC*HC:98765*150*140
DTM*472*20120124
CAS*PR*3*10
REF*0K*8910
SVC*HC:26591*75*75
DTM*472*20120124
PLB*1215193883*20121231*90*3.95
SE*31*112233
Human readable HIPAA EDI 835
BPR*I*391.05*C*ACH*CCP*01*322271724*DA*203158175*8076853391**01*122000496*DA*7341099666*20120131
Transaction Handling Code : Remittance Information Only
Monetary Amount : $391.05
Credit/Debit Flag Code : Credit
Payment Method Code : Automated Clearing House (ACH)
Payment Format Code : Cash Concentration/Disbursement plus Addenda (CCD+) (ACH)
(DFI) ID Number Qualifier : ABA Transit Routing Number Including Check Digits (9 digits)
(DFI) Identification Number : 322271724
Account Number Qualifier : Demand Deposit
Account Number : 203158175
Originating Company Identifier : 8076853391
(DFI) ID Number Qualifier : ABA Transit Routing Number Including Check Digits (9 digits)
(DFI) Identification Number : 122000496
Account Number Qualifier : Demand Deposit
Account Number : 7341099666
Date : 1/31/2012
Trace: TRN*1*051036622050010*1262721578
Trace Type Code : Current Transaction Trace Numbers
Reference Identification (Check or EFT Trace Number):: 051036622050010
Originating Company Identifier (Federal Tax ID Number, preceded by a “1”): 1262721578
Payer: N1*PR*BCBS DISNEY
BCBS DISNEY
POBLADO RD
LOS ANGELES, CA 9006
Contact Information: PER*BL*MICHAEL EISNER*TE*7145205060*EX*123*EM*edi@bcbsdisney.com
Technical Department : MICHAEL EISNER
Telephone : 7145205060
Telephone Extension : 123
Electronic Mail: edi@bcbsdisney.com
Information Contact : PER*IC**UR*www.bcbsdisney.com/policies.html
Uniform Resource Locator (URL) : http://www.bcbsdisney.com/policies.html
Payee: N1*PE*UCLA MEDICAL CENTER*XX*1215193883
UCLA MEDICAL CENTER (Centers for Medicare and Medicaid Services National Provider Identifier: 1215193883)
Claim Level Data: CLP*ABC9001*1*225*200*5*12*1142381711242*22*1
Claim Submitter’s Identifier : ABC9001
Claim Status Code : Processed as Primary
Charge Amount : 225
Paid Amount : 200
Patient Responsibility Amount : 5
Claim Filing Indicator Code : Preferred Provider Organization (PPO)
Reference Identification : 1142381711242
Facility Code Value : 22
Claim Frequency Type Code : 1
Claims Adjustment: CAS*CO*45*20
Claim Adjustment Group Code : Contractual Obligations
Claim Adjustment Reason Code: 45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
Adjustment Amount : 20
Patient Name: NM1*QC*1*MOUSE*MICKEY****MI*60345914A
Entity Identifier Code : Patient
Entity Type Qualifier : Person
Name Last or Organization Name : MOUSE
Name First : MICKEY
Identification Code Qualifier : Member Identification Number
Identification Code : 60345914A
Service Information: SVC*HC:98765*150*145
Composite Medical Procedure Identifier : Health Care Financing Administration Common Procedural Coding System (HCPCS) , 98765
Charge Amount : 150
Paid Amount : 145
Date/Time Reference: DTM*472*20120124
Service : 1/24/2012
Claims Adjustment: CAS*PR*3*5
Claim Adjustment Group Code : Patient Responsibility
Claim Adjustment Reason Code : 3 – Co-Payment Amount
Monetary Amount : 5
Reference Information: REF*0K*8910
Policy Form Identifying Number : 8910
Service Information: SVC*HC:26591*75*75
Composite Medical Procedure Identifier : Health Care Financing Administration Common Procedural Coding System (HCPCS) , 26591
Line Item Charge Amount : 75
Line Item Charge Amount : 75
Date/Time Reference: DTM*472*20120124
Service : 1/24/2012
Claim Level Data: CLP*ABC9002*1*225*195*10*12*1142381711242*22*1
Claim Submitter’s Identifier : ABC9002
Claim Status Code : Processed as Primary
Charge Amount : 225
Paid Amount : 195
Patient Responsibility Amount: 10
Claim Filing Indicator Code : Preferred Provider Organization (PPO)
Reference Identification : 1142381711242
Facility Code Value : 22
Claim Frequency Type Code : 1
Claims Adjustment: CAS*CO*45*20
Claim Adjustment Group Code : Contractual Obligations
Claim Adjustment Reason Code : 45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.
Adjustment Amount : 20
Patient Name: NM1*QC*1*DUCK*DONALD****MI*60345914B
Entity Identifier Code : Patient
Entity Type Qualifier : Person
Name Last or Organization Name : DUCK
Name First : DONALD
Identification Code Qualifier : Member Identification Number
Identification Code : 60345914B
Service Information: SVC*HC:98765*150*140
Composite Medical Procedure Identifier : Health Care Financing Administration Common Procedural Coding System (HCPCS) , 98765
Charge Amount : 150
Paid Amount : 140
Date/Time Reference: DTM*472*20120124
Service : 1/24/2012
Claims Adjustment: CAS*PR*3*10
Claim Adjustment Group Code : Patient Responsibility
Claim Adjustment Reason Code : 3 Co-Payment
Adjustment Amount : 10
Reference Information: REF*0K*8910
Policy Form Identifying Number : 8910
Service Information: SVC*HC:26591*75*75
Composite Medical Procedure Identifier : Health Care Financing Administration Common Procedural Coding System (HCPCS) , 26591
Charge Amount : 75
Paid Amount : 75
Date/Time Reference DTM*472*20120124
Service : 1/24/2012
Provider Level Adjustment: PLB*1215193883*20121231*90*3.95
Reference Identification : 1215193883
Date : 12/31/2012
Adjustment Identifier : Early Payment Allowance
Monetary Amount : 3.95.
Service Level Balancing Formula Check
These segments can be found in LOOP 2110:
Claim 1 – Submitted Charges (SVC02 $150) – Sum of Adjustments ($5 CAS-03, CAS-06, CAS-09, CAS-12, CAS-15, CAS-18) = Service Amount Paid ($145 SVC03)
SVC*HC:98765*150*145
DTM*472*20120124
CAS*PR*3*5
SVC*HC:26591*75*75
Claim 2 – Submitted Charges (SVC02 $150) – Sum of Adjustments ($10 CAS-03, CAS-06, CAS-09, CAS-12, CAS-15, CAS-18) = Service Amount Paid ($140 SVC03)
SVC*HC:98765*150*140
DTM*472*20120124
CAS*PR*3*10
SVC*HC:26591*75*75
Claim Level Balancing Formula Claim:
These segments can be found in LOOP 2100:
Claim 1 Submitted Charges (CLP-03 $225) – Sum of Adjustments ($20 AND $5 CAS-03, CAS-06, CAS-09, CAS-12, CAS-15, CAS-18) = Claim Paid (CLP-04 $200)
CLP*ABC9001*1*225*200*5*12*1142381711242*22*1
CAS*CO*45*20
NM1*QC*1*MOUSE*MICKEY****MI*60345914A
SVC*HC:98765*150*145
DTM*472*20120124
Claim 2 Submitted Charges (CLP-03 $225) – Sum of Adjustments ($20 AND $10CAS-03, CAS-06, CAS-09, CAS-12, CAS-15, CAS-18) = Claim Paid (CLP-04 $195)
CLP*ABC9002*1*225*195*10*12*1142381711242*22*1
CAS*CO*45*20
NM1*QC*1*DUCK*DONALD****MI*60345914B
SVC*HC:98765*150*140
DTM*472*20120124
CAS*PR*3*10
Transaction Level Balancing Formula
These segments can be found in LOOP 2100 and Table 1 and Table 3:
Sum of All Claim Payments (Sum of all CLP04 $395) – Sum of All Provider Adjustments (SUM of PLB04 $3.95, 06, 08, 10, 12, and 14) = Total Payment Amount ($391.05 BPR-02)
BPR*I*391.05*C*ACH*CCP*01*322271724*DA*203158175*8076853391**01*122000496*DA*7341099666*20120131
CLP*ABC9002*1*225*195*10*12*1142381711242*22*1
CLP*ABC9001*1*225*200*5*12*1142381711242*22*1
PLB*1215193883*20121231*90*3.95
NOTE: Adjustments within the 835, through use of the Claim Adjustment and Service Adjustment Segments, CAS, or Provider Level Adjustment Segments, PLB, DECREASE the payment when the adjustment amount is POSITIVE, and INCREASE the payment when the adjustment amount is NEGATIVE.