Interactive Examples of Healthcare Claim Payments in X12 EDI

This section contains examples of payments for healthcare claims. All examples are provided by

We use 835 transaction for payments. Payments are issued in response to claims submitted using 837 transaction set. Even though there are three different flavors of 837 (professional, institutional, dental), the 835 format is the same for all these claim types. 835 can also be used to pay for pharmacy claims.

In general, the structure if 835 matches 837. BPR segment is used to communicate the payment mechanism and the amount. Then the amount is broken up by claims in CLP segments and then further by service lines in SVC segments. So the purpose of 835 is to explain what claims and services are being paid.

The patient control number element (the very first element of CLP) is used to correlate the information in CLP with the data from the original claim and its CLM segment.

Examples are rendered using EDI Viewer components of our Claim Insight ETL and analytics platform. We’re currently providing beta access to the EDI Viewer and Claim Insight. If you’d like to be able to use the same intuitive UI for your own X12 EDI data, please get in touch with us via this form.

All examples are interactive. Mouse over any portion of an EDI string to see the definition of an EDI element. You can also click on the segment ID (two or three-letter segment identifier) to view all the elements and descriptions in a convenient tabular form.

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