Version 1.0 of the X12 835 EOD Posting File leverages the ASC X12N standard format for Electronic Remittance Advice for the purpose of posting patient to provider payments.
File Name Standard: [Account Name]_dpa835_[Date in YYYYMMDD]_[seq#].rep
| SEG | Field ID | Field Name | Format | Required? | Config? | Expected Value | Comments |
|---|---|---|---|---|---|---|---|
| BPR | Financial Information | ||||||
| BPR01 | Transaction Handling Code | AN | Y | Y | "H" | ||
| BPR02 | Payment Amount | DEC | Y | Amount | |||
| BPR03 | Credit/Debit Flag Code | AN | Y | "C" or "D" | Payment Transaction action - sale = C; refund = D. | ||
| BPR04 | Payment Method Code | AN | Y | Y | "NON" | ||
| BPR05 | Payment Format Code | S | Not currently used. | ||||
| BPR06 | (DFI) ID Number Qualifier | S | Not currently used. | ||||
| BPR07 | (DFI) Identification Number | S | Not currently used. | ||||
| BPR08 | Account Number Qualifier | S | Not currently used. | ||||
| BPR09 | Account Number | S | Not currently used. | ||||
| BPR10 | Originating Company Identifier | AN | S | Y | "1999999999" | ||
| BPR11 | Originating Company Supplemental Code | AN | S | Y | "credit card," "eCheck," "cash," "manual check" | Transaction Type: Credit Card, eCheck, cash, manual check. | |
| BPR12 | Depository Financial Institution | S | Not currently used. | ||||
| BPR13 | Provider Bank ID Number | S | Not currently used. | ||||
| BPR14 | Account Number Qualifier | S | Not currently used. | ||||
| BPR15 | Provider Account Number | Y | Not currently used. | ||||
| BPR16 | Check Issue or EFT Effective Date | DT | S | Business Date | |||
| TRN | Reassociation Trace Number | ||||||
| TRN01 | Trace Type Code | AN | Y | "1" | |||
| TRN02 | Check or EFT Trace Number | AN | Y | Y | Authorization Number | ||
| TRN03 | Originating Company Identifier | AN | Y | Y | "1999999999" | ||
| TRN04 | Originating Company Supplemental Code | AN | S | Y | "credit card," "eCheck," "cash," "manual check" | "Transaction Type: Credit Card, eCheck, cash, manual check. | |
| N1 | Payer Identification | ||||||
| N101 | Entity Identifier Code | AN | Y | "PR" | |||
| N102 | Name | AN | Y | Patient First Name + Patient Last Name | If not available, use "Patient"; max 60 characters. | ||
| N103 | Identification Code Qualifier | AN | Y | "XV" | |||
| N104 | Payer Identifier | AN | Y | Y | Patient Account Number | If not available, use "9999" . | |
| N3 | Payer Address | ||||||
| N301 | Payer Address Line | AN | Y | Y | Patient Address 1 | ||
| N302 | Payer Address Line | AN | S | Y | Patient Address 2 if available | ||
| N4 | "Payer City, State, ZIP Code" | ||||||
| N401 | Payer City Name | AN | Y | Y | Patient City | If not available, use "City". | |
| N402 | State or Province Code | AN | Y | Y | Patient State | If not available, use "CA". | |
| N403 | Payer Postal Zone | AN | Y | Y | Patient Zip Code | If not available, use "9999". | |
| N1 | Payee Identification | ||||||
| N101 | Entity Identifier Code | AN | Y | "PE" | |||
| N102 | Payee Name | AN | S | Merchant Name | |||
| N103 | Identification Code Qualifier | AN | Y | "FI" | |||
| N104 | Payee Identification Code | AN | Y | Merchant ID | The unique ID associated with your merchant processing account, which will be given by your Implementations Manager. | ||
| REF | Payee Additional Identification | ||||||
| REF01 | Reference Identification Qualifier | AN | Y | "PQ" | |||
| REF02 | Additional Payee Identifier | AN | Y | Merchant|Store|Terminal ID | The unique ID associated with your merchant processing account, which will be given by your Implementations Manager. | ||
| CLP | Claim Payment Information | ||||||
| CLP01 | Claim Submitter's Identifier | AN | Y | Y | Patient Account Number | If not available, use "9999". | |
| CLP02 | Claim Status Code | AN | Y | "0" OR "1" OR "22" | Sale = 1; Refund = 22; Default = 0. | ||
| CLP03 | Total Claim Charge Amount | DEC | Y | Amount | |||
| CLP04 | Claim Payment Amount | DEC | Y | Amount | |||
| CLP05 | Patient Responsibility Amount | DEC | S | "0" | |||
| CLP06 | Claim Filing Indicator Code | AN | Y | Y | "13" | ||
| CLP07 | Payer Claim Control Number | AN | S | Y | Transaction ID | ||
| CLP08 | Facility Code Value | S | Not currently used. | ||||
| CLP09 | Claim Frequency Code | S | Not currently used. | ||||
| CLP10 | Patient Status Code | S | Not currently used. | ||||
| CLP11 | Diagnosis Related Group (DRG) Code | S | Not currently used. | ||||
| CLP12 | Diagnosis Related Group (DRG) Weight | S | Not currently used. | ||||
| CLP13 | Discharge Fraction | S | Not currently used. | ||||
| NM1 | Patient Name | ||||||
| NM101 | Entity Identifier Code | AN | Y | "QC" | |||
| NM102 | Entity Type Qualifier | AN | Y | "1" | |||
| NM103 | Patient Last Name | AN | Y | Patient Last Name | If not available, use "Patient Last". | ||
| NM104 | Patient First Name | AN | S | Patient First Name | If not available, use "Patient First". | ||
| NM105 | Patient Middle Name | AN | S | Patient Middle Name | If not available, use "Patient Middle". | ||
| NM106 | Name Prefix | S | Not currently used. | ||||
| NM107 | Name Suffix | S | Not currently used. | ||||
| NM108 | Identification Code Qualifier | AN | Y | "MI" | |||
| NM109 | Patient Identifier | AN | Y | Y | Patient Account Number | If not available, use "9999". | |
| REF | Other Claim Related Identification | ||||||
| REF01 | Qualifier | AN | Y | "BB" OR "EA" | BB = Auth Code; EA = Med Rec#. | ||
| REF02 | Identifier | AN | Y | Authorization Number/Medical Record # | |||
| DTM | Claim Date | ||||||
| DTM01 | Qualifier | AN | Y | 232/233 to convey service start and end date | If not available, use transaction date. | ||
| DTM02 | Date | DT | Y | Service start and end date | |||
| PER | Claim Contact Information | ||||||
| PER01 | Contact Function Code | AN | Y | CX - Payers Claim Office | |||
| PER02 | Claim Contact Name | AN | S | User ID | |||
| PER03 | Communication Number Qualifier | S | Not currently used. | ||||
| PER04 | Claim Contact Communications Number | S | Not currently used. | ||||
| PER05 | Communication Number Qualifier | S | Not currently used. | ||||
| PER06 | Claim Contact Communications Number | S | Not currently used. | ||||
| PER07 | Telephone Extension | S | Not currently used. | ||||
| PER08 | Communication Number | S | Not currently used. | ||||