Member Claim Level File

InstaMed supports the ability to send payments (and denials) to members (Explanation of Benefits or EOB). These outbound payments consist of claims adjudicated by a health plan and owed to a member.

In order to properly reflect the disposition of an adjudicated claim, issued via the InstaMed Disbursement Hub solution, InstaMed supports the generation of claim-level batch files.

For example, if a check payment, consisting of 5 claims, was issued for $1,000, each of these claims would be reported as an individual row in the batch file with a ‘Paid’ status. InstaMed will output another batch file in the future when the check is deposited to change the status of each of the claims from ‘Paid’ to ‘Settled’.

The specification below is used to report on the status of specific claims issued by InstaMed as part of a payment/835 transaction.

Files are output in a pipe delimited format and uploaded to client-specific SFTP directories.

Field #	Field Name	Format	Min	Max	Required	Comment
1	Record ID	"IMCRE10"	7	7	Y
2	ClaimID	AN	1	18	S	Internal Claim ID REF*9A field
3	PayerClaimNumber	AN	1	30	N	CLP07
4	ClaimSubmitterIdentifier	AN	1	38	Y	CLP01
5	ClaimCharges	DEC			Y	CLP03
6	ClaimPayment	DEC			S	CLP04 - Available when transaction status is Fulfilled
7	PaymentDate	AN	8	8	S	YYYYMMDD, Available when transaction status is Fulfilled
8	DisbursmentTraceNumber	AN	1	30	S	TRN02 - Disbursed check/trace number to provider; Available when transaction status is Fulfilled
9	DisbursmentEntity	AN	10	42	S	TRN03:TRN04 - Available when transaction status is Fulfilled
10	FundingTraceNumber	AN	1	30	S	From original file -- TRN02
11	FundingEntity	AN	10	42	S	From original file -- TRN03:TRN04
12	Payer Name	AN	1	35	Y	N102 when N101 = PR
13	Payee Last	AN	1	35	Y	N102 when N101 = PE
14	Payee First	AN	1	35	S
15	Payee Primary ID Qualifier	AN	2	2	Y	N103 when N101 = PE
16	Payee Primary ID	AN	1	80	Y	N104 when N101 = PE
17	Patient Last Name	AN	1	35	Y	NM103 when NM101 = QC
18	Patient First Name	AN	1	35	Y	NM104 when NM101 = QC
19	Patient Middle Name	AN	1	25	S	NM105 when NM101 = QC
20	Patient ID Qualifier	AN	2	2	Y	NM108 when NM101 = QC
21	Patient ID	AN	1	80	Y	NM109 when NM101 = QC
22	Status	AN	1	20	Y	FULFILLED: Disbursed payments SUSPENDED: Suspended payments SETTLED: Settled payments PENDING APPROVAL: Payments that are available for approval in InstaMed Online VOIDED: Payments were voided by client via their bank RETURNED: Returned payments STOPPED: Payments were stopped by client via their bank REMOVED: Payments was removed from Pending Approval
23	Freeform	AN	1	100	S
24	Mail Date	AN	8	8	S	YYYYMMDD Date that print vendor placed item into mailstream; Always populated for CHK
25	Placeholder Field 2	AN				Reserved for future use
26	Placeholder Field 3	AN				Reserved for future use
27	Placeholder Field 4	AN				Reserved for future use
28	Placeholder Field 5	AN				Reserved for future use
29	Placeholder Field 6	AN				Reserved for future use
30	Placeholder Field 7	AN				Reserved for future use
31	Placeholder Field 8	AN				Reserved for future use
32	Placeholder Field 9	AN				Reserved for future use
33	Placeholder Field 10	AN				Reserved for future use
34	Placeholder Field 11	DEC				Reserved for future use
35	Placeholder Field 12	DEC				Reserved for future use
36	Placeholder Field 13	DEC				Reserved for future use
37	Placeholder Field 14	DEC				Reserved for future use
38	Placeholder Field 15	DEC				Reserved for future use