835 ERA Objects and Fields

Overview

Root objects:

Payment (adjudicated claim); CLP segment
ProviderAdjustment (provider-level adjustment); PLB segment

Resources:

Payment

Loop: 2100, Segment: CLP JSON Example Interactive Example Open API Schema

Name	Description	Type	EDI Element
id	Unique payment identifier assigned by the converter	String
objectType	Type of this object, set to 'PAYMENT'	String
patientControlNumber	Identifier used to track a claim from creation by the health care provider through payment	String Required	CLP01
chargeAmount	Charge amount	Number Required	CLP02
paymentAmount	Payment amount	Number Required	CLP04
facilityCode	Place of service code (professional/dental) or UB facility code (institutional) from the original claim View codes and descriptions	Code	CLP08
frequencyCode	Frequency code View codes and descriptions	Code	CLP09
statementDateFrom	Statement date from	Date	DTP03 *232
statementDateTo	Statement date to	Date	DTP03 *233
serviceDateFrom	The earliest service date from service lines	Date
serviceDateTo	The latest service date from service lines	Date
subscriber	The insured (subscriber) from the original claim if the insured is different from the patient	PatientSubscriber835	Loop: 2100
patient	The insured (subscriber) or patient from the original claim	PatientSubscriber835	Loop: 2100
otherSubscribers	Other subscriber; only one other subscriber is allowed on 835	List of PatientSubscriber835	Loop: 2100
serviceLines	Service lines	List of PaymentLine	Loop: 2110
transaction	Parent EDI transaction for this object	Transaction835
claimStatusCode	Claim status code	String	CLP02
claimStatus	Claim status code translated to a string constant (enum), such as PRIMARY,SECONDARY	String	CLP02
patientResponsibilityAmount	Patient responsibility amount	Number	CLP05
claimFilingIndicatorCode	Claim filing indicator code	String	CLP06
insurancePlanType	Claim filing indicator code translated to a string constant (enum), such as PPO, HMO	String	CLP06
payerControlNumber	Payer control number	String	CLP07
drg	Diagnosis-related group code. Institutional claims only.	Code	CLP11
drgWeight	Adjudicated DRG weight. Institutional claims only.	Number	CLP12
dischargeFraction	Adjudicated discharge fraction. Institutional claims only. This is a percentage expressed as decimal.	Number	CLP13
otherClaimRelatedIds	Other claim-related identifications	List of Reference	REF
supplementalAmounts	Supplemental claim/payment amounts, such as coverage amount, discount amount, etc.	List of Amount	AMT
supplementalQuantities	Supplemental claim/payment quantities	List of Quantity	QTY
payer	Payer	Party	N1 *PR
payee	Payee	Party	N1 *PE
outpatientAdjudication	Outpatient adjudication	OutpatientAdjudication	MOA
inpatientAdjudication	Inpatient adjudication	InpatientAdjudication	MIA
adjustments	Claim adjustments	List of Adjustment	CAS
coverageExpirationDate	Coverage expiration date	Date	DTP03 *036
claimReceivedDate	Claim received date	Date	DTP03 *050
serviceProvider	Service provider	PartyIdName	NM1 *SJ
crossoverCarrier	Crossover carrier	PartyIdName	NM1 *TT
correctedPayer	Corrected priority payer, meaning that current payer believes that another payer has priority for making a payment	PartyIdName	NM1 *PR
correctedInsured	Corrected insured	PartyIdName	NM1 *74
claimContacts	Claim contacts	List of ContactInfo

Service Line

Loop: 2110, Segment: SVC Open API Schema

Name	Description	Type	EDI Element
sourceLineId	Line item control number	String	REF02 *6R
repricedReferenceNumber	Repriced reference number	String	REF02 *9B
adjustedRepricedReferenceNumber	Adjusted repriced reference number	String	REF02 *9D
healthcarePolicyId	Healthcare policy id	String	REF02 *0K
chargeAmount	Charge amount	Number Required
paidAmount	Paid amount	Number Required	SVC03
supplementalAmounts	Supplemental amounts, such as allowed amount, deduction amount, etc.	List of Amount	AMT
supplementalQuantities	Supplemental quantities	List of Quantity	QTY
serviceDateFrom	Service date from	Date	DTP03 *472
serviceDateTo	Service date to	Date	DTP03 *472
unitType	Unit type	String
unitCount	Unit count	Number	SVC05
originalUnitCount	Original unit count	Number	SVC07
drug	Drug code (NDC) View codes and descriptions	Code	SVC01
procedure	Procedure View codes and descriptions	Procedure	SVC01 HC, SVC01 AD, SVC01 WK, SVC01 IV
revenueCode	Revenue code View codes and descriptions	Code	SVC01 RC,NU, SVC04 RC,NU
originalProcedure	Submitted procedure code from the claim if it is different from the adjudicated procedure View codes and descriptions	Procedure	SVC06 HC, SVC06 AD, SVC06 WK, SVC06 IV
originalRevenueCode	Submitted revenue code from the claim if it is different from the adjudicated revenue code View codes and descriptions	Code	SVC06 *RC,NU
originalDrug	Submitted drug (NDC) code from the claim if it is different from the adjudicated drug code View codes and descriptions	Code	SVC06
providers	Providers for this service line	List of Provider
adjustments	Line adjustments	List of Adjustment	CAS
remarkCodes	Remark codes View codes and descriptions	List of String	LQ
remarks	Remark codes View codes and descriptions	List of Code	LQ
serviceIds	Related service-specific identifiers that were used in the process of adjudicating this service	List of Reference	REF
renderingProviderIds	Rendering provider identifiers	List of Reference	REF

Adjustment

Segment: CAS Open API Schema

Name	Description	Type	EDI Element
group	Claim adjustment group code as a string constant (enum)	String Required	CAS01
reason	Claim adjustment reason code View codes and descriptions	Code Required	CAS02
amount	Adjustment amount	Number Required	CAS03
quantity	Adjustment quantity	Number	CAS04

Outpatient Adjudication

Contains Remittance Advice Remark Codes at the claim level and/or Medicare or Medicaid-specific amounts for outpatient claims

Segment: MOA Open API Schema

Name	Description	Type	EDI Element
reimbursementRate	Reimbursement rate	Number	MOA01
hcpcsPayableAmount	Claim HCPCS Payable Amount	Number	MOA02
esrdPaymentAmount	Esrd payment amount	Number	MOA08
nonPayableProfessionalComponentAmount	Nonpayable Professional Component Amount	Number	MOA09
remarks	Remark codes View codes and descriptions	List of Code	MOA3:7

Inpatient Adjudication

Contains Remittance Advice Remark Codes at the claim level and/or Medicare or Medicaid-specific amounts for inpatient institutional claims

Segment: MIA Open API Schema

Name	Description	Type	EDI Element
coveredDaysOrVisitsCount	Covered days or visits count	Integer Required	MIA01
ppsOperatingOutlierAmount	Pps operating outlier amount	Number	MIA02
lifetimePsychiatricDaysCount	Lifetime psychiatric days count	Integer	MIA03
drgAmount	Drg amount	Number	MIA04
disproportionateShareAmount	Disproportionate share amount	Number	MIA06
mspPassThroughAmount	Msp pass through amount	Number	MIA07
ppsCapitalAmount	Pps capital amount	Number	MIA08
ppsCapitalFspDrgAmount	Pps capital fsp drg amount	Number	MIA09
ppsCapitalHspDrgAmount	Pps capital hsp drg amount	Number	MIA10
ppsCapitalDshDrgAmount	Pps capital dsh drg amount	Number	MIA11
oldCapitalAmount	Old capital amount	Number	MIA12
ppsCapitalImeAmount	Pps capital ime amount	Number	MIA13
ppsOperatingHospitalSpecificDrgAmount	Pps operating hospital specific drg amount	Number	MIA14
costReportDayCount	Cost report day count	Integer	MIA15
ppsOperatingFederalSpecificDrgAmount	Pps operating federal specific drg amount	Number	MIA16
ppsCapitalOutlierAmount	Pps capital outlier amount	Number	MIA17
indirectTeachingAmount	Indirect teaching amount	Number	MIA18
nonPayableProfessionalComponentAmount	Non payable professional component amount	Number	MIA19
ppsCapitalExceptionAmount	Pps capital exception amount	Number	MIA24
remarks	Remark codes View codes and descriptions	List of Code	MIA3

Patient or Subscriber

Insured subscriber of patient for 835

Open API Schema

Name	Description	Type	EDI Element
person	Person	Party	NM1

Organization Or Person ID and Name

Open API Schema

Name	Description	Type	EDI Element
entityRole	Entity role View codes and descriptions	String Required	NM101, N101
entityType	Type of this entity: 'BUSINESS' for organization, 'INDIVIDUAL' for person	String Required	NM102
identificationType	Identification type, e.g., NPI or EIN. This is a qualifier code translated to a string constant (enum)	String	NM108, N103
identifier	Identifier	String	NM109, N104
taxId	Tax id	String	REF02 TJ, REF02 SY, REF02 *EI
lastNameOrOrgName	Organization name or person last name	String	NM103, N102
firstName	First name	String	NM104
middleName	Middle name	String	NM105

Organization or Person (Party)

Open API Schema

Extends: PartyIdName

Name	Description	Type	EDI Element
address	Address	Address
contacts	Contacts	List of ContactInfo
additionalIds	Other identifications	List of Reference	REF

Address

Open API Schema

Name	Description	Type	EDI Element
line	Line	String	N301
line2	Line2	String	N302
city	City	String	N401
stateCode	State code	String	N402
zipCode	Zip code	String	N403
countryCode	Country code	String	N404

Contact Info

Segment: PER Open API Schema

Name	Description	Type	EDI Element
functionCode	Function code	String Required	PER01
name	Name	String	PER02
contactNumbers	Contact numbers	List of ContactNumber

Contact Number

Segment: PER Open API Schema

Name	Description	Type	EDI Element
type	Type of contact number, such as PHONE, EMAIL, URL	String Required	PER03,PER05,PER07
number	Number	String Required	PER04,PER06,PER08

Procedure

Procedure code with description and optional modifiers

Segment: HI,SV1,SV2,SV3,SVC Open API Schema

Extends: Code

Name	Description	Type	EDI Element
modifiers	Modifiers	List of Code	837P:SV101-3-6, 837I:SV201-3-6, 835:SVC01-3-6, 277:SVC01-3-6

Code

Code and description

Open API Schema

Name	Description	Type
subType	Healthcare code subtype, such as CPT, HCPCS, ICD_10, NDC	String
code	Healthcare code	String Required
desc	Code description	String

Amount

Segment: AMT Open API Schema

Name	Description	Type	EDI Element
qualifierCode	Code specifying the type of amount (amount qualifier code)	String Required	AMT01
type	Type of amount; qualifier code translated to a mnemonic string constant (enum) View codes and descriptions	String	AMT01
amount	Amount	Number Required	AMT02

Quantity

Segment: QTY Open API Schema

Name	Description	Type	EDI Element
qualifierCode	Code specifying the type of quantity (quantity qualifier code)	String Required	QTY01
type	Type of quantity; qualifier code translated to a mnemonic string constant (enum) View codes and descriptions	String	QTY01
quantity	Quantity	Number Required	QTY02

Reference Identifications

Segment: REF Open API Schema

Name	Description	Type	EDI Element
qualifierCode	Code qualifying the reference identification	String Required	REF01
type	Type of reference; qualifier code as a string constant (enum) View codes and descriptions	String	REF01
identification	Reference identification	String Required	REF02

Provider-Level Adjustment

Provider level adjustment information for debit or credit transactions such as, accelerated payments, cost report settlements for a fiscal year and timeliness report penalties unrelated to a specific claim or service

Segment: PLB JSON Example Open API Schema

Name	Description	Type	EDI Element
id	Unique payment identifier assigned by the converter	String
objectType	Type of this object, always set to 'PROVIDER_ADJUSTMENT'	String
providerIdentifier	Provider identifier	String Required	PLB01
fiscalPeriodDate	Fiscal period date	Date Required	PLB02
adjustments	Adjustments	List of ProviderAdjustmentReasonAmount
payer	Payer	Party	N1 *PR
payee	Payee	Party	N1 *PE
transaction	Parent EDI transaction for this adjustment	Transaction835

Provider-Level Adjustment’s Reason and Amount

Provider-level payment adjustment containing the reason code and the amount

Open API Schema

Name	Description	Type	EDI Element
reason	Provider adjustment reason code View codes and descriptions	Code Required	PLB03-1
referenceIdentification	Reference identification	String	PLB03-2
amount	Amount	Number Required	PLB04

EDI Transaction Info

Open API Schema

Name	Description	Type	EDI Element
controlNumber	Control number	String	ST02
transactionType	Transaction type translated to string constant, PROF for 837P, INST for 837I, etc.	String	ST01, ST03
productionDate	Production date	Date	DTP03 *405
transactionHandlingType	Transaction handling type	String Required	BPR01
totalPaymentAmount	Total payment amount	Number Required	BPR02
creditOrDebitFlagCode	Credit or debit flag code	String Required	BPR03
paymentMethodType	Payment method type: ACH, CHECK, WIRE_TRANSFER, NON_PAYMENT	String Required	BPR04
paymentFormatCode	Payment format code	String	BPR05
senderBankRoutingNumber	Sender bank routing number	String	BPR07
senderAccountNumber	Sender account number	String	BPR09
originatingCompanyId	If provided, should be identical to payerIdentifier	String	BPR10
originatingCompanySupplementalCode	Originating company supplemental code	String	BPR11,TRN04
receiverBankRoutingNumber	Receiver bank routing number	String	BPR13
receiverAccountNumber	Receiver account number	String	BPR15
paymentDate	Payment date	Date Required	BPR16
checkOrEftTraceNumber	Check or eft trace number	String Required	TRN02
payerIdentifier	This must be a 1 followed by the payer's EIN or TIN. This ID will be used as the identifier in the payer object if no other identifier was provided	String Required	TRN03
receiverIdentifier	Receiver's identifier when different from payee (e.g., a clearinghouse)	String	REF02 *EV
transactionSetIdentifierCode	Transaction set identifier code	String	ST01
implementationConventionReference	Implementation convention reference	String	ST03
fileInfo	File info	FileInfo

File Info

Open API Schema

Name	Description	Type
name	File name	String
url	URL of the file, including the full path	String
lastModifiedDateTime	Last modified date and time of the file	Date and Time