HIPAA Transaction Standard Companion Guide 835

 

Health Care Claim Payment /Advice

Refers to the X12N Implementation Guide ANSI Version 4010X091 and 4010X091A1

The Optima Health 835 Companion Guide is to be used with the HIPAA-AS Implementation Guide, which provides comprehensive information needed to create an ANSI 835 transaction.  The Optima Health Companion Guide is used in conjunction with the HIPAA Implementation Guide; it is intended to clarify issues where the HIPAA Implementation Guide provides options or choices to be made.  Download the HIPAA Implementation Guide from: http://www.wpc-edi.com/hipaa/HIPAA_40.asp

LEGEND for Optima Health Matrix for 835

Shaded rows represent segments; Non-shaded rows represent "data elements."

*Members in the Optima Health system can uniquely be identified using their unique member number.  Dependent loops and Hierarchy Levels will not be used.

 

Page #

Loop ID

Reference

Name

Codes

Notes/Comments

 

 

ISA

Interchange Control Header

 

 

 

 

ISA04

 

 

SENTARAADS

198 (B.4)

 

ISA07

Interchange ID Qualifier

ZZ

 

199

 

ISA08

Interchange Receiver ID

SUNTRUST

 

199

 

ISA16

Component Element Separator

>

 

202

 

GS

Functional Group Header

 

 

 

 

GS03

Application Receiver Code

SUNTRUST

 

44

 

BPR

Financial Information

 

 

45

 

BPR01

Transaction Handling Code

D

D = Make Payment Only

46

 

BPR02

Monetary Amount

 

Check amount

46

 

BPR03

Credit/Debit Flag Code

C

Credit

46

 

BPR04

Payment Method Code

ACH

Automated Clearing House

47

 

BPR05

Payment Format Code

CTX

Corporate Trade Exchange

48

 

BPR06

(DFI) ID Number Qualifier

01

ABA Transit Routing Number including Check digits (9 digits)

48

 

BPR07

(DFI) ID Number

 

SUNTRUST Routing Number

49

 

BPR09

Account Number

 

Sender Bank Acct Number

49

 

BPR10

Originating Company Identifier

 

1+Tax ID number - must be identical to TRN03

49

 

BPR11

Originating Company Supplemental Code

 

 

49

 

BPR12

DFI ID No Qualifier

01

ABA Transit Routing Number Including Check Digits (9 digits)

50

 

BPR13

DFI ID Number

 

Provider Bank Routing #

50

 

BPR14

Account Number Qualifier

SG or DA

Provider Bank Account Type  DA = Demand Deposit;  SG = Savings

50

 

BPR15

Account Number

 

Provider Bank Account Number

50

 

BPR16

Date

 

Current Date (CCYYMMDD)

52

 

TRN

Reassociation Trace Number

 

 

52

 

TRN01

Trace Type Code

1

Current Transaction Trace Numbers

53

 

TRN02

Reference Ident

 

Optima Check Number

53

 

TRN03

Originating Company ID