Section title: X12 EDI Examples
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ASC X12 Version: 005010 | Transaction Set: 835 | TR3 ID: 005010X221

Example 01: Dollars and Data Sent Separately

This scenario depicts the use of the 835 in a managed care environment. The funds are moved separately from the remittance detail. In this scenario, the funds are sent by EFT to the provider's account and the remittance advice is sent to the provider.

The following assumptions pertain to this scenario:

  • The dollars move from the Hudson River Bank, ABA# 888999777, account number 24681012 to the Amazon Bank, ABA# 111333555, checking account number 144444 using the ACH network. The money moves on March 16, 2019.
  • The insurance company, Rushmore Life, Federal Tax ID # 935665544, is paying ACME Medical Center, National Provider ID 5544667733 & Federal Tax ID # 777667755, a total of $1100.00. The first patient's name is William Budd, patient number 5554555444 and member ID # 33344555510. Total reported charges are $800.00. Amount paid is $500.00. Patient responsibility is $300.00.
  • The second patient's name is Susan Settle, patient number 8765432112 and member ID # 44455666610. Total reported charges are $1200.00. Amount paid is $600.00. Patient responsibility is $600.00.

 

Transmission

ISA*00*          *00*          *ZZ*ABCPAYER       *ZZ*ABCPAYER       *190827*0212*^*00501*191511902*0*P*:~

GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~

ST*835*112233~

BPR*I*1100*C*ACH*CCP*01*888999777*DA*24681012*1935665544**01*111333555*DA*144444*20190316~

TRN*1*71700666555*1935665544~

DTM*405*20190314~

N1*PR*RUSHMORE LIFE~

N3*10 SOUTH AVENUET~

N4*RAPID CITY*SD*55111~

PER*BL*JOHN WAYNE*TE*8005551212*EX*123~

N1*PE*ACME MEDICAL CENTER*XX*5544667733~

REF*TJ*777667755~

LX*1~

CLP*5554555444*1*800*500*300*12*94060555410000*11*1~

NM1*QC*1*BUDD*WILLIAM****MI*33344555510~

AMT*AU*800~

SVC*HC:99211*800*500~

DTM*472*20190301~

CAS*PR*1*300~

AMT*B6*800~

CLP*8765432112*1*1200*600*600*12*9407779923000*11*1~

NM1*QC*1*SETTLE*SUSAN****MI*44455666610~

AMT*AU*1200~

SVC*HC:93555*1200*600~

DTM*472*20190310~

CAS*PR*1*600~

AMT*B6*1200~

SE*26*112233~

GE*1*12345678~

IEA*1*191511902~