EDI 835 Health Care Claim Payment/Advice

Looking for best Practice Management software ? Please email at vbsenthilinnet@gmail.com

If you are new to Medical Billing, then please read this article first.
If you are new to EDI, then  read the following articles

1. What is an EDI ?
2. EDI Transactions 
3. Understanding EDI Structure
4. EDI Instruction

EDI 835 Health Care Claim Payment/Advice

The 835 is used primarily by Healthcare insurance plans to make payments to healthcare providers, to provide Explanations of Benefits (EOBs), or both. When a healthcare service provider submits an 837 Health Care Claim, the insurance plan uses the 835 to detail the payment to that claim, including:

• What charges were paid, reduced or denied
• Whether there was a deductible, co-insurance, co-pay, etc.
• Any bundling or splitting of claims or line items
• How the payment was made, such as through a clearinghouse

A particular 835 document may not necessarily match up one-for-one with a specific 837. In fact, it is not uncommon for multiple 835 transactions to be used in response to a single 837, or for one 835 to address multiple 837 submissions. As a result, the 835 is important to healthcare providers, to track what payments were received for services they provided and billed. And also one EDI 835 File, may contain multiple Checks i.e Multiple EOBs

Before going into detail, Let us understand how insurance Payer make the Payment. Please understand and have good understanding on the following topics.

1. What is Copay, Co Insurance and Deductible in  Insurance Payment Posting ?
2. EOB – Explanation of Benefits

 

I have developed a small Parsing tool in VB.NET/VB.6/Java . This tool will take the EDI File and convert into PDF File as shown here.

 

Looking for best Practice Management software ? Please email at vbsenthilinnet@gmail.com 

Questions or feedback are always welcome. You can email me at vbsenthilinnet@gmail.com