EDI 835-W1 Health Care Claim Payment/Advice

What is an EDI 835-W1 Health Care Claim Payment/Advice? 

One of the X12 transactions, EDI 835-W1 is used by healthcare service providers to make payments or send an Explanation of Benefits (EOB). This document is organized into different data elements and segments that contain the following information: 

• The charges paid 
• The mode of payment 
• The claim details, such as deductibles, co-insurance, and co-pay  

EDI X12 835-W1 Health Care Claim Payment/Advice Sample

An EDI X12 835-W1 document is divided into functional groups that explain the contents of the transaction being conducted. The following example details the format of this document[1].

ST*835*1234~
BPR*I*15096.46*C*CHK************20100923~
TRN*1*70408535*15714001~
REF*F2*slca435w~
DTM*405*20100923~
N1*PR*NC TEACHERS & STATE EMPLOYEES HEALTH PLAN & HEALTH CHOICE~
N3*P O BOX 30025~
N4*DURHAM*NC*27702~
PER*CX**TE*8002144844~
N1*PE*ACME UNIV HLTH SYS INC*XX*1234567890~
N3*P O BOX AAA1~
N4*DURHAM*NC*27701~
REF*TJ*123456789~
CLP*474623UB001CW0321*1*3740.6*5451.04**15*80209000000*11*1**397*0.7309~
CAS*CO*94*-1710.44~
NM1*QC*1*Rabbit*Roger*B***MI* RUN123456789~
MIA*0~
REF*EA*CW0321~
DTM*232*20100307~
DTM*233*20100310~
DTM*50*20100918~
AMT*AU*5451.04~
SE*21*1234~

Workflow for the Exchange of an EDI 835-W1 Health Care Claim Payment/Advice

This EDI document falls under the category of the X12N Insurance transactions. Upon receiving an EDI 837 Health Care Claim transaction set, the healthcare service providers send the EDI 835 document for making a payment or providing an explanation of benefits (EOB).

Stay EDI Compliant with Astera EDIConnect

Designed to facilitate electronic data interchange, Astera EDIConnect is an enterprise-grade, code-free solution that supports EDIFACT and ANSI X12 EDI formats. With a built-in parser, validator, and transaction builder, Astera EDIConnect makes the process of sending and receiving EDI documents simple and easy.

[1]https://www.bluecrossnc.com/sites/default/files/document/attachment/providers/public/pdfs/835_5010_v2.6%20Claim%20Payment%20Advice.pdf