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 |
|
|
|
|
|
TRN01 |
Trace Type Code |
1 |
Current Transaction Trace Numbers |
|
53 |
|
TRN02 |
Reference Ident |
|
Optima Check Number |
|
53 |
|
TRN03 |
Originating Company ID |
|
|