Section title: X12 EDI Examples
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X12 Version: 008060 | Transaction Set: 835 | TR3 ID: 008060X322

Example 03: 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 RAS 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 the provider liability in this example.

Transmission

ISA*00*          *00*          *ZZ*ABCPAYER       *ZZ*ABCPROVIDER    *250827*0212*^*00806*191511902*0*P*:~

GS*HP*ABCD*ABCD*20250827*12345678*12345678*X*008060X322~

ST*835*35681~

BPR*I*132*C*CHK************20250827~

TRN*1*12345*1512345678~

REF*EV*CLEARINGHOUSE~

DTM*405*20250827~

N1*PR*DELTA DENTAL OF ABC~

N3*225 MAIN STREET~

N4*CENTERVILLE*PA*17111~

PER*BL*EDI*TE*9005555555~

N1*PE*PROVIDER 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~

DTM*050*20250809~

AMT*AU*132~

SVC*AD:D0120*46*25~

DTM*472*20250724~

RAS*21*CO*131~

AMT*B6*25~

SVC*AD:D0220*25*14~

DTM*472*20250724~

RAS*11*CO*131~

AMT*B6*14~

SVC*AD:D0230*22*10~

DTM*472*20250724~

RAS*12*CO*131~

AMT*B6*10~

SVC*AD:D0274*60*34~

DTM*472*20250724~

RAS*26*CO*131~

AMT*B6*34~

SVC*AD:D1110*73*49~

DTM*472*20250724~

RAS*24*CO*131~

AMT*B6*49~

SE*38*35681~

GE*1*12345678~

IEA*1*191511902~