5010 835 Examples
Jurisdiction 1 Part B
ANSI v5010: Examples of ANSI v5010 Base Health Care Claim Payment/Advice 835
The Centers for Medicare & Medicaid Services (CMS) has begun the implementation process to convert from ANSI Version 4010A1 to ANSI Version 5010 base and errata. This conversion process will impact the Health Care Claim Payment/Advice 835 electronic remittance transaction.
The following are examples of an ANSI 835 electronic remittance transaction in the 5010 base version. These examples are subject to change and are not inclusive. Your data will differ.
Example 1 – Showing Payment
ST*835*000000001~
BPR*I*297.66*C*ACH*CCP*01*111000012*DA*00000001234567894*1123456789**01*062001319*DA*8765431190*20090901~
TRN*1*888881234*1112345678~
REF*EV*SSSSSS~
DTM*405*20090828~
N1*PR*MEDICARE PART B~
N3*1234 ANY STREET~
N4*ANYTOWN*SC*292011234~
REF*2U*PPPPP~
PER*CX*MEDICARE PART B*TE*8665551212~
PER*BL*PROVIDER SUPPORT*TE*8665551212*TE*8665551212*FX*8035551212~
N1*PE*PHYSICIANS LTD*XX*111111111~
N3*ONE MAIN STREET~
N4*ANYTOWN*SC*292011234~
REF*TJ*1123456789~
LX*1~
CLP*A9800078*19*2000*297.66*74.41*MB*2209229100360*11*1~
NM1*QC*1*SAMPLE*PATIENT*G***HN*111111111F~
NM1*74*1**PATIENCE~
NM1*TT*2*CROSSOVER COMPANY*****PI*11111~
MOA***MA01*MA18~
REF*EA*797828~
DTM*050*20090817~
SVC*HC:72141*2000*297.66**1~
DTM*472*20090815~
CAS*CO*45*1627.93~
CAS*PR*2*74.41~
REF*LU*11~
REF*6R*20793~
AMT*B6*372.07~
SE*31*000000001~
Example 2 – Showing No payment
ST*835*000000006~
BPR*H*0*C*NON************20090901~
TRN*1*300000973*1112345678~
REF*EV*SSSSSS~
DTM*405*20090828~
N1*PR*MEDICARE PART B~
N3*1234 ANYSTREET~
N4*ANYTOWN*SC*292011234~
REF*2U*PPPPP~
PER*CX*MEDICARE PART B*TE*8665551212~
PER*BL*PROVIDER SUPPORT*TE*8665551212*TE*8665551212*FX*8035551212~
PER*IC**UR*WWW.PALMETTOGBA.COM~
N1*PE*JOHN SMITH MD*XX*111111111~
N3*TWO ANYSTREET ~
N4*ANYTOWN*SC*292011234~
REF*TJ*1123456789~
LX*0~
CLP*0*1*2500*0*0*MB*2709181280010*22~
NM1*QC*1*SAMPLE*PATIENCE****HN*111111111F~
NM1*74*1***M~
MOA***MA28~
DTM*050*20090630~
SVC*HC:66984:RT*2500*0**0~
DTM*472*20090222~
CAS*CO*50*2500~
REF*LU*22~
REF*6R*01~
REF*0K*L26793~
LQ*HE*M26~
LQ*HE*N115~
SE*89*000000006~
If you have any questions regarding this information, please contact our EDI Technology Support Center at (866) 749-4301.
last updated on 01/13/2011