Health Care Claim Payment/Advice
The HIPAA X12 835 explains how a payer adjudicated a claim — what was paid, denied, or adjusted, and why — while optionally carrying the actual payment.
In this guide
835 Remittance Advice moves from Payer / Health Plan to Provider / Clearinghouse (Payer → Provider) via AS2, SFTP, API. The interactive diagram below traces every business and technical step the message passes through — press Play Flow to watch it travel, or click any step for detail.
How it works
How 835 Remittance Advice Works
Sender
Payer / Health Plan
Receiver
Provider / Clearinghouse
Direction
Payer → Provider
Standard
ANSI ASC X12
Version
005010X221
Transport
AS2 / SFTP / API
Business Purpose
Healthcare
Sender — Payer / Health Plan
EDI Transmission
835
Health Care Claim Payment/Advice
ANSI ASC X12 005010X221
Receiver — Provider / Clearinghouse
Related transaction flows
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Ask EDI AI →835 Remittance Advice workflow. Steps: Adjudicate Claims, Generate 835 EDI, Send to Provider, Clearinghouse / Provider Receives, Auto-Post Payment, Route Denials. Transmitted from Payer / Health Plan to Provider / Clearinghouse via AS2, SFTP, API, following ANSI ASC X12 005010X221.
Overview
Automates payment posting in the provider's billing system, matching payments and adjustments to the original claim without manual re-keying of a paper Explanation of Benefits.
Sender
Payer / Health Plan
Receiver
Provider / Clearinghouse
Direction
Payer → Provider
Standard / Version
ANSI ASC X12 005010X221
Segment structure
Key segments that make up this transaction set:
| Segment | Name | Purpose |
|---|---|---|
| BPR | Beginning Segment for Payment Order/Remittance Advice | Total payment amount and method. |
| CLP | Claim Payment Information | Claim-level billed, allowed, and paid amounts. |
| SVC | Service Payment Information | Service-line level payment detail. |
| CAS | Claim Adjustment | Reason codes and amounts for reductions from the billed amount. |
Interactive example
Click any segment below to see its business meaning.
ST
This is an envelope or control segment. Select a highlighted segment on the left (shown in green) for a full business explanation.
View raw EDI
ST*835*0001*005010X221~
BPR*I*478.00*C*ACH*CTX*01*021000021*DA*1234567890**01*091000019*DA*9876543210*20230925~
TRN*1*RA-99120~
N1*PR*Acme Health Plan~
N1*PE*Riverside Medical Group*XX*1932837465~
CLP*CLM-556210*1*550.00*478.00*72.00*12*PAYER-CLM-90142~
NM1*QC*1*DOE*JANE~
SVC*HC:99214*550.00*478.00**1~
CAS*CO*45*72.00~
SE*11*0001~Mapping example
A representative field-level mapping from a common source system into this transaction:
| Source | Source Field | Target Field |
|---|---|---|
| Payer Adjudication Output | claim.paid_amount | CLP04 (Claim Payment Amount) |
| Payer Adjudication Output | claim.adjustment_reason | CAS02 (Claim Adjustment Reason Code) |
| Payer Adjudication Output | serviceLine.allowed_amount | SVC03 (Line Item Provider Payment Amount) |
Validation rules
- CLP03 (billed) minus all CAS amounts must reconcile to CLP04 (paid) plus CLP05 (patient responsibility).
- CAS reason codes must be valid, current Claim Adjustment Reason Codes (CARC) and Group Codes.
- BPR02 total payment must equal the sum of all CLP04 amounts in the transaction.
Common errors & troubleshooting
Auto-posting fails to balance a claim
Cause: SVC-level adjustments don't sum correctly to the claim-level CLP adjustment total.
Fix: Validate that service-line CAS amounts reconcile to claim-level totals before transmission.
Provider disputes a denial they can't understand
Cause: Only a generic CARC code was sent without a corresponding Remittance Advice Remark Code (RARC) for detail.
Fix: Populate MIA/MOA or LQ remark code segments alongside CAS whenever a denial or reduction needs further explanation.
Frequently asked questions
Not necessarily — some 835s are remittance-advice-only (BPR04 = NON, meaning no funds transfer), with payment made separately by check or a different ACH transaction.
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