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

Example 3: Claim Specific Negotiated Discount

In this example the provider and payer came to an agreed upon amount for allowance for these specific services billed which happened to be less than billed charges. The difference between the billed charge and the negotiated amount is shown as an adjustment in a CAS segment. The claim adjustment reason code would be 131 "Claim specific negotiated discount". Group code CO (contractual obligation) would be used as the adjustment amount is provider liability in this example.

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*35681~

BPR*I*132*C*CHK************20190331~

TRN*1*12345*1512345678~

REF*EV*CLEARINGHOUSE~

N1*PR*DELTA DENTAL OF ABC~

N3*225 MAIN STREET~

N4*CENTERVILLE*PA*17111~

PER*BL*JANE DOE*TE*9005555555~

N1*PE*BAN DDS LLC*FI*999994703~

LX*1~

CLP*7722337*1*226*132**12*119932404007801~

NM1*QC*1*DOE*SALLY****MI*SJD11111~

NM1*82*1*BAN*ERIN****XX*1811901945~

AMT*AU*132~

SVC*AD:D0120*46*25~

DTM*472*20190324~

CAS*CO*131*21~

AMT*B6*25~

SVC*AD:D0220*25*14~

DTM*472*20190324~

CAS*CO*131*11~

AMT*B6*14~

SVC*AD:D0230*22*10~

DTM*472*20190324~

CAS*CO*131*12~

AMT*B6*10~

SVC*AD:D0274*60*34~

DTM*472*20190324

CAS*CO*131*26~

AMT*B6*34~

SVC*AD:D1110*73*49~

DTM*472*20190324~

CAS*CO*131*24~

AMT*B6*49~

SE*34*35681~

GE*1*12345678~

IEA*1*191511902~