X12 835 remittance advice (ERA): format and example

835 structure

The full X12 835 layout from its OpenEDI definition, the same model ediFabric uses to parse, validate and generate it: 5 loops and 53 segment positions, in file order. Loops are shaded and their segments indented; Max use is how many times a segment or loop may repeat.

Segment / loop	Name	Usage	Max use
`ST`	Transaction Set Header	Required	1
`BPR`	Financial Information	Required	1
`TRN`	Reassociation Trace Number	Required	1
`CUR`	Foreign Currency Information	Situational	1
Any order	The loops below can appear in any order	Situational	1
`REF`	Receiver Identification	Situational	1
`REF`	Version Identification	Situational	1
`DTM`	Production Date	Situational	1
Any order	The loops below can appear in any order	Required	1
Loop 1000A	Payer Identification	Required	1
`N1`	Payer Identification	Required	1
`N3`	Payer Address	Required	1
`N4`	Payer City State ZIP Code	Required	1
`REF`	Additional Payer Identification	Situational	4
Any order	The loops below can appear in any order	Required	1
`PER`	Payer Business Contact Information	Situational	1
`PER`	Payer Technical Contact Information	Required	>1
`PER`	Payer WEB Site	Situational	1
Loop 1000B	Payee Identification	Required	1
`N1`	Payee Identification	Required	1
`N3`	Payee Address	Situational	1
`N4`	Payee City State ZIP Code	Situational	1
`REF`	Payee Additional Identification	Situational	>1
`RDM`	Remittance Delivery Method	Situational	1
Loop 2000	Header Number	Situational	>1
`LX`	Header Number	Required	1
`TS3`	Provider Summary Information	Situational	1
`TS2`	Provider Supplemental Summary Information	Situational	1
Loop 2100	Claim Payment Information	Required	>1
`CLP`	Claim Payment Information	Required	1
`CAS`	Claims Adjustment	Situational	99
Any order	The loops below can appear in any order	Required	1
`NM1`	Patient Name	Required	1
`NM1`	Insured Name	Situational	1
`NM1`	Corrected Patient Insured Name	Situational	1
`NM1`	Service Provider Name	Situational	1
`NM1`	Crossover Carrier Name	Situational	1
`NM1`	Corrected Priority Payer Name	Situational	1
`NM1`	Other Subscriber Name	Situational	1
`MIA`	Inpatient Adjudication Information	Situational	1
`MOA`	Outpatient Adjudication Information	Situational	1
Any order	The loops below can appear in any order	Situational	1
`REF`	Other Claim Related Identification	Situational	5
`REF`	Rendering Provider Identification	Situational	10
Any order	The loops below can appear in any order	Situational	1
`DTM`	Statement Fromor to Date	Situational	2
`DTM`	Coverage Expiration Date	Situational	1
`DTM`	Claim Received Date	Situational	1
`PER`	Claim Contact Information	Situational	2
`AMT`	Claim Supplemental Information	Situational	13
`QTY`	Claim Supplemental Information Quantity	Situational	14
Loop 2110	Service Payment Information	Situational	999
`SVC`	Service Payment Information	Required	1
`DTM`	Service Date	Situational	2
`CAS`	Service Adjustment	Situational	99
Any order	The loops below can appear in any order	Situational	1
`REF`	Service Identification	Situational	8
`REF`	Line Item Control Number	Situational	1
`REF`	Rendering Provider Information	Situational	10
`REF`	Health Care Policy Identification	Situational	5
`AMT`	Service Supplemental Amount	Situational	9
`QTY`	Service Supplemental Quantity	Situational	6
`LQ`	Health Care Remark Codes	Situational	99
`PLB`	Provider Adjustment	Situational	>1
`SE`	Transaction Set Trailer	Required	1

Usage follows the 005010X221A1 implementation guide: Required segments must be sent, Situational ones only when the guide's condition applies. Trading partners often add their own rules in companion guides - ediFabric templates can be adjusted to match. Open the element-level definition in the EdiNation spec library.

Sample 835 file

A remittance for one payment with claim-level and service-level adjustments. Paste it into EdiNation to see every element named and validated.

ISA*00*          *00*          *ZZ*1234567        *ZZ*11111          *170508*1141*^*00501*000000101*1*P*:~
GS*HC*XXXXXXX*XXXXX*20170617*1741*101*X*005010X221A1~
ST*835*0001~
BPR*I*34.00*C*CHK************20050318~
TRN*1*0063158ABC*1566339911~
REF*EV*030240928~
DTM*405*20050318~
N1*PR*YOUR TAX DOLLARS AT WORK~
N3*481A00 DEER RUN ROAD~
N4*WEST PALM BCH*FL*11114~
PER*BL*JOHN WAYNE*TE*8005551212*EX*123~
N1*PE*ATONEWITHHEALTH*FI*3UR334563~
N3*3501 JOHNSON STREET~
N4*SUNSHINE*FL*12345~
REF*PQ*11861~
LX*1~
CLP*0001000055*2*541*34**12*50650619501~
NM1*QC*1*BURCK*RAYMOND*W***MI*987654321~
NM1*82*2*PROFESSIONAL TEST 1*****BS*34426~
DTM*232*20050202~
DTM*233*20050202~
SVC*HC:55669*541*34*1~
DTM*472*20050202~
CAS*OA*23*516~
CAS*OA*94*-9~
REF*1B*44280~
AMT*B6*550~
SE*26*0001~
GE*1*101~
IEA*1*000000101~

The same 835 as JSON

ediFabric turns every loop, segment and element into a named field. This is the transaction from the sample, in the JSON that ediFabric Native and Cloud return and accept.

{
  "ST": {
    "TransactionSetIdentifierCode_01": "835",
    "TransactionSetControlNumber_02": "0001"
  },
  "BPR_FinancialInformation": {
    "TransactionHandlingCode_01": "I",
    "TotalPremiumPaymentAmount_02": "34.00",
    "CreditorDebitFlagCode_03": "C",
    "PaymentMethodCode_04": "CHK",
    "CheckIssueorEFTEffectiveDate_16": "20050318"
  },
  "TRN_ReassociationTraceNumber": {
    "TraceTypeCode_01": "1",
    "CurrentTransactionTraceNumber_02": "0063158ABC",
    "OriginatingCompanyIdentifier_03": "1566339911"
  },
  "AllREF": {
    "REF_ReceiverIdentification": {
      "ReferenceIdentificationQualifier_01": "EV",
      "MemberGrouporPolicyNumber_02": "030240928"
    }
  },
  "DTM_ProductionDate": {
    "DateTimeQualifier_01": "405",
    "Date_02": "20050318"
  },
  "AllN1": {
    "Loop1000A": {
      "N1_PayerIdentification": {
        "EntityIdentifierCode_01": "PR",
        "PremiumPayerName_02": "YOUR TAX DOLLARS AT WORK"
      },
      "N3_PayerAddress": {
        "ResponseContactAddressLine_01": "481A00 DEER RUN ROAD"
      },
      "N4_PayerCity_State_ZIPCode": {
        "AdditionalPatientInformationContactCityName_01": "WEST PALM BCH",
        "AdditionalPatientInformationContactStateCode_02": "FL",
        "AdditionalPatientInformationContactPostalZoneorZIPCode_03": "11114"
      },
      "AllPER": {
        "PER_PayerTechnicalContactInformation": [
          {
            "ContactFunctionCode_01": "BL",
            "ResponseContactName_02": "JOHN WAYNE",
            "CommunicationNumberQualifier_03": "TE",
            "ResponseContactCommunicationNumber_04": "8005551212",
            "CommunicationNumberQualifier_05": "EX",
            "ResponseContactCommunicationNumber_06": "123"
          }
        ]
      }
    },
    "Loop1000B": {
      "N1_PayeeIdentification": {
        "EntityIdentifierCode_01": "PE",
        "PremiumPayerName_02": "ATONEWITHHEALTH",
        "IdentificationCodeQualifier_03": "FI",
        "IntermediaryBankIdentifier_04": "3UR334563"
      },
      "N3_PayeeAddress": {
        "ResponseContactAddressLine_01": "3501 JOHNSON STREET"
      },
      "N4_PayeeCity_State_ZIPCode": {
        "AdditionalPatientInformationContactCityName_01": "SUNSHINE",
        "AdditionalPatientInformationContactStateCode_02": "FL",
        "AdditionalPatientInformationContactPostalZoneorZIPCode_03": "12345"
      },
      "REF_PayeeAdditionalIdentification": [
        {
          "ReferenceIdentificationQualifier_01": "PQ",
          "MemberGrouporPolicyNumber_02": "11861"
        }
      ]
    }
  },
  "Loop2000": [
    {
      "LX_HeaderNumber": {
        "AssignedNumber_01": "1"
      },
      "Loop2100": [
        {
          "CLP_ClaimPaymentInformation": {
            "PatientControlNumber_01": "0001000055",
            "ClaimStatusCode_02": "2",
            "TotalClaimChargeAmount_03": "541",
            "ClaimPaymentAmount_04": "34",
            "ClaimFilingIndicatorCode_06": "12",
            "PayerClaimControlNumber_07": "50650619501"
          },
          "AllNM1": {
            "NM1_PatientName": {
              "EntityIdentifierCode_01": "QC",
              "EntityTypeQualifier_02": "1",
              "ResponseContactLastorOrganizationName_03": "BURCK",
              "ResponseContactFirstName_04": "RAYMOND",
              "ResponseContactMiddleName_05": "W",
              "IdentificationCodeQualifier_08": "MI",
              "ResponseContactIdentifier_09": "987654321"
            },
            "NM1_ServiceProviderName": {
              "EntityIdentifierCode_01": "82",
              "EntityTypeQualifier_02": "2",
              "ResponseContactLastorOrganizationName_03": "PROFESSIONAL TEST 1",
              "IdentificationCodeQualifier_08": "BS",
              "ResponseContactIdentifier_09": "34426"
            }
          },
          "AllDTM": {
            "DTM_StatementFromorToDate": [
              {
                "DateTimeQualifier_01": "232",
                "Date_02": "20050202"
              },
              {
                "DateTimeQualifier_01": "233",
                "Date_02": "20050202"
              }
            ]
          },
          "Loop2110": [
            {
              "SVC_ServicePaymentInformation": {
                "CompositeMedicalProcedureIdentifier_01": {
                  "ProductorServiceIDQualifier_01": "HC",
                  "ProcedureCode_02": "55669"
                },
                "LineItemChargeAmount_02": "541",
                "MonetaryAmount_03": "34",
                "RevenueCode_04": "1"
              },
              "DTM_ServiceDate": [
                {
                  "DateTimeQualifier_01": "472",
                  "Date_02": "20050202"
                }
              ],
              "CAS_ServiceAdjustment": [
                {
                  "ClaimAdjustmentGroupCode_01": "OA",
                  "AdjustmentReasonCode_02": "23",
                  "AdjustmentAmount_03": "516"
                },
                {
                  "ClaimAdjustmentGroupCode_01": "OA",
                  "AdjustmentReasonCode_02": "94",
                  "AdjustmentAmount_03": "-9"
                }
              ],
              "AllREF": {
                "REF_RenderingProviderInformation": [
                  {
                    "ReferenceIdentificationQualifier_01": "1B",
                    "MemberGrouporPolicyNumber_02": "44280"
                  }
                ]
              },
              "AMT_ServiceSupplementalAmount": [
                {
                  "AmountQualifierCode_01": "B6",
                  "TotalClaimChargeAmount_02": "550"
                }
              ]
            }
          ]
        }
      ]
    }
  ],
  "SE": {
    "NumberofIncludedSegments_01": "26",
    "TransactionSetControlNumber_02": "0001"
  }
}

Parse and validate an 835 file

Read the file into typed objects with ediFabric .NET, convert it to JSON in process with the ediFabric Native bindings for Python, Java and C, or post it to the ediFabric Cloud REST API from any language.

.NET
Python
Java
C
Cloud

using EdiFabric.Templates.Hipaa5010;

License.SetSerial("YOUR_SERIAL_KEY");

using (var stream = File.OpenRead(@"C:\edi\Payment.txt"))
using (var reader = new X12Reader(stream, "EdiFabric.Templates.Hipaa"))
{
    var items = await reader.ReadToEndAsync();
    foreach (var transaction in items.OfType<TS835>())
    {
        if (transaction.IsValid(out MessageErrorContext errors))
            Console.WriteLine($"{transaction.ST.TransactionSetControlNumber_02} is valid");
        else
            Console.WriteLine(string.Join(Environment.NewLine, errors.Flatten()));
    }
} Install and get started 835 example project Walkthrough
import json
import edifabric_x12 as ef

serial = "YOUR_SERIAL_KEY"
ef.load_library()
ef.set_serial(serial)
ef.set_map(json.dumps({"default": serial, "maps": {}}))

edi = open("Payment.txt", "rb").read()
output, offset = ef.parse(edi, ef.ParseMode.JSON_VALIDATE)
transactions = output[:offset]
report = json.loads(output[offset:])
print(report["errors_count"]) Python bindingsediFabric Native
import com.edifabric.nativex12.EdiFabricX12;
import com.edifabric.nativex12.ParseMode;
import com.edifabric.nativex12.ParseResult;

String serial = "YOUR_SERIAL_KEY";
EdiFabricX12.loadLibrary();
EdiFabricX12.setSerial(serial);
EdiFabricX12.setMap("{\"default\":\"" + serial + "\",\"maps\":{}}");

String edi = Files.readString(Path.of("Payment.txt"));
ParseResult result = EdiFabricX12.parse(edi, ParseMode.JSON_VALIDATE);
System.out.println(result.getTransactions());
System.out.println(result.getReport()); Java bindingsediFabric Native
#include "edifabric_x12.h"

const char *serial = "YOUR_SERIAL_KEY";
ef_parse_result result;

if (ef_load_library(NULL) != 0)
    return 1;
ef_set_serial(serial);
ef_set_map("{\"default\":\"YOUR_SERIAL_KEY\",\"maps\":{}}");

char *edi = read_file("Payment.txt", NULL);   /* helper in example_all_functions.c */
if (ef_parse(edi, EF_PARSE_JSON_VALIDATE, NULL, &result) == 0) {
    /* transactions = output[0 .. offset), report = output[offset .. length) */
    fwrite(result.output.data, 1, (size_t)result.output.length, stdout);
    ef_free(result.output.data);
} C bindingsediFabric Native
curl -X POST 'https://api.edination.com/v2/x12/read' \
-H 'Ocp-Apim-Subscription-Key: YOUR_SERIAL_KEY' \
-H 'Content-Type: application/octet-stream' \
--data-binary '@Payment.txt' TranslateValidateediFabric Cloud

Generate an 835 file

Populate a TS835 object in .NET, or pass JSON in the shape shown above to ediFabric Native or ediFabric Cloud, and get a valid 835 file back.

.NET
Python
Java
C
Cloud

using EdiFabric.Templates.Hipaa5010;

License.SetSerial("YOUR_SERIAL_KEY");

var transaction = new TS835();

transaction.ST = new ST();
transaction.ST.TransactionSetIdentifierCode_01 = "835";
transaction.ST.TransactionSetControlNumber_02 = "0001";

transaction.BPR_FinancialInformation = new BPR_FinancialInformation_2();
transaction.BPR_FinancialInformation.TransactionHandlingCode_01 = "I";
transaction.BPR_FinancialInformation.TotalPremiumPaymentAmount_02 = "34.00";
transaction.BPR_FinancialInformation.CreditorDebitFlagCode_03 = "C";
transaction.BPR_FinancialInformation.PaymentMethodCode_04 = "CHK";
transaction.BPR_FinancialInformation.CheckIssueorEFTEffectiveDate_16 = "20050318";

transaction.TRN_ReassociationTraceNumber = new TRN_DependentTraceNumber();
transaction.TRN_ReassociationTraceNumber.TraceTypeCode_01 = "1";
transaction.TRN_ReassociationTraceNumber.CurrentTransactionTraceNumber_02 = "0063158ABC";
transaction.TRN_ReassociationTraceNumber.OriginatingCompanyIdentifier_03 = "1566339911";

//  Occurrence of REF Segments in any order
transaction.AllREF = new All_REF_835_3();

// ... set the remaining loops and segments the same way

// SegmentBuilders is in the Common project of the example repository
using (var stream = new MemoryStream())
{
    using (var writer = new X12Writer(stream))
    {
        writer.Write(SegmentBuilders.BuildIsa("1"));
        writer.Write(SegmentBuilders.BuildGs("1", "SENDER1", "RECEIVER1", "005010X221A1"));
        writer.Write(transaction);
    }
    Console.WriteLine(Encoding.UTF8.GetString(stream.ToArray()));
} Install and get started Full 835 build methodExample repository
import json
import edifabric_x12 as ef

serial = "YOUR_SERIAL_KEY"
ef.load_library()
ef.set_serial(serial)
ef.set_map(json.dumps({"default": serial, "maps": {}}))

# the transactions JSON returned by ef.parse, edited or produced by your application
transactions = open("Payment.json", "rb").read()
edi = ef.build(transactions, postfix="\r\n")
print(edi) Python bindings
import com.edifabric.nativex12.EdiFabricX12;

String serial = "YOUR_SERIAL_KEY";
EdiFabricX12.loadLibrary();
EdiFabricX12.setSerial(serial);
EdiFabricX12.setMap("{\"default\":\"" + serial + "\",\"maps\":{}}");

// the transactions JSON returned by parse, edited or produced by your application
String transactions = Files.readString(Path.of("Payment.json"));
String edi = EdiFabricX12.build(transactions, "\r\n");
System.out.println(edi); Java bindings
#include "edifabric_x12.h"

ef_buffer edi;

if (ef_load_library(NULL) != 0)
    return 1;
ef_set_serial("YOUR_SERIAL_KEY");
ef_set_map("{\"default\":\"YOUR_SERIAL_KEY\",\"maps\":{}}");

/* the transactions JSON returned by ef_parse, edited or produced by your application */
char *transactions = read_file("Payment.json", NULL);
if (ef_build(transactions, "\r\n", &edi) == 0) {
    fwrite(edi.data, 1, (size_t)edi.length, stdout);
    ef_free(edi.data);
} C bindings
# the JSON returned by /read, edited or produced by your application
curl -X POST 'https://api.edination.com/v2/x12/write' \
-H 'Ocp-Apim-Subscription-Key: YOUR_SERIAL_KEY' \
-H 'Content-Type: application/json' \
--data-binary '@Payment.json' \
-o 'Payment.txt' How-tosediFabric Cloud

835 questions

How do I match an 835 to the bank deposit?

TRN02 is the check or EFT trace number and BPR02 the payment amount. The same trace number is sent with the ACH CCD+ payment, so the two can be reassociated automatically.

What do the CAS group codes mean?

CAS01 groups each adjustment: CO contractual obligation, PR patient responsibility, OA other adjustments, PI payer initiated reductions. CAS02 is the claim adjustment reason code (CARC).

Does an 835 always carry a payment?

No. BPR04 NON means no payment, for example when every claim was denied or the payment was sent separately. BPR01 H is notification only.

How do I parse and generate X12 835 files in .NET, Python, Java and C?

In .NET, install EdiFabric and EdiFabric.Templates.Hipaa, read the file with X12Reader into TS835 objects and write them back with X12Writer. From Python, Java or C, use ediFabric Native, which converts 835 files to JSON and JSON back to X12 inside your process. From any other language, post the file to the ediFabric Cloud REST API.

Related transactions

X12 837P - Health Care Claim: Professional
X12 837I - Health Care Claim: Institutional
X12 837D - Health Care Claim: Dental
X12 277 - Health Care Claim Status Response
All EDI transactions →

X12 835 Health Care Claim Payment/Advice

At a glance