Electronic Remittance Advice 835 Transaction Companion Guide

Electronic Remittance Advice
835 Transaction Companion Guide

Release 2.0
to the
Health Care Claim Payment/Advice

(ASC X12N 004010X091A1)
Implementation Guide
May 1, 2008
835 Transaction Companion Guide (Release 2.0)
Table of Contents ________________________________

Introduction.............................................................................................................................................. 3
Establishing Connectivity....................................................................................................................... 4
Confidentiality, Privacy and Security...................................................................................................... 4
Setup........................................................................................................................................................ 5
Technical Requirements .......................................................................................................................... 5
File-Naming Convention......................................................................................................................... 6
ERA Structure. .......................................................................................................................................... 6
835 Content.............................................................................................................................................. 7
Conditional Data Requirements ......................................................................................................... 10
Provider Level Adjustments (PLB) ......................................................................................................... 10
Interest Payments .................................................................................................................................. 10
Matching Process ................................................................................................................................... 10
Claim & Service Line Adjustments ........................................................................................................ 11
Adjustments (Reversals & Corrections)................................................................................................. 11
Mapping Non-Standard Codes.............................................................................................................. 11
Attachment A: Frequently Asked Questions ................................................................................... 13
Attachment B: Matching Examples.................................................................................................... 15
Attachment C: Reversal and Correction............................................................................................ 22
Attachment D: Deny Codes .................................................................................................................. 24
Attachment E: Calculation of Allowed Amount ............................................................................. 32
Attachment F: 835 Electronic Remittance Advice Specifications ............................................... 33
Harvard Pilgrim Health Care 2 May 1, 2008

Introduction _____________________________________
The Health Insurance Portability and Accountability Act–Administration Simplification
(HIPAA–AS) requires Harvard Pilgrim Health Care and all other covered entities to comply with
the electronic data interchange standards for health care as established by the Secretary of Health
and Human Services. Harvard Pilgrim supports the batch ASC X12N 004010X091A1 Electronic
Remittance Advice (ERA) 835 transaction with Payment by Check as specified in Section 2.1.2.1
of the May 2000 Health Care Claim Payment/Advice Implementation Guide available at
www.wpc-edi.com/HIPAA. At this time, Harvard Pilgrim does not support electronic funds
transfer via the 835 transaction or any other available channel or transaction.
This guide has been prepared to help those responsible for testing and setting up electronic health
care claim payment/advice. Specifically, it documents and clarifies when conditional data elements
and segments must be used for reporting, and it identifies codes and data elements that do not apply to
Harvard Pilgrim. This guide supplements (but does not contradict) any requirements in the ASC X12N
004010X091A1 Implementation Guide.
The intended audience for this document is the technical area responsible for programming to
receive files and automatically post electronic claims payment advice to the provider’s accounts
receivable (A/R) system. This information should be also coordinated with the provider’s accounts
receivable office to ensure differences between the Harvard Pilgrim 835 ERA and paper Explanation
of Payments are interpreted and posted correctly.

Establishing Connectivity ________________________

Harvard Pilgrim offers the 835 ERA transaction through the New England Health EDI Network
(NEHEN), HPHConnect, NEHENNet, dial-up to a Bulletin Board System (BBS) and secure File
Transfer Protocol (FTP). Each method (or portal) has its respective user identifiers (ID), trading
partner IDs, file names and methods of delivery.
The 835/ERA transaction files for legacy products are generated weekly and are usually available by
close-of-business, Wednesdays. The 835/ERA transaction files for Choice Plus and Options
products are generated daily, and are usually available the next business day.
If you have questions, please contact:
Harvard Pilgrim EDI Team
Phone: 800-708-4414 option 1, then option 3
Fax: 617-509-1165
E-mail: edi_team@hphc.org
Confidentiality, Privacy and Security

Maintaining the confidentiality of personal health information continues to be one of Harvard
Pilgrim’s guiding principles. Harvard Pilgrim has a strict Confidentiality Policy with regard to
safeguarding patient, employee, and health plan information. All staff is required to be familiar with,
and comply with, Harvard Pilgrim’s policy on the Confidentiality of Member Personal and Clinical
Information to ensure that all member information is treated in a confidential and respectful
manner. The policy permits use or disclosure of members’ medical or personal information only as
necessary to conduct required business, care management, approved research or quality assurance or
measurement activities, or when authorized to do so by a member or as required by law.
To comply with internal policies as well as the provisions of the Health Insurance Portability and
Accountability Act, 1996 (HIPAA), Harvard Pilgrim has outlined specific requirements applicable to the
electronic exchange of Protected Health Information (PHI) including provisions for:
Maintaining confidentiality of protected information
Confidentiality safeguards
Security standards
Return or destruction of protected information
Compliance with state and federal regulatory and statutory requirements
Required disclosure
Use of business associates
These requirements are detailed in the Privacy and Security Agreement presented to Harvard
Pilgrim’s electronic trading partners during our initial discussions.
Harvard Pilgrim offers a variety of solutions to transmit PHI using a public network. In
accordance with Harvard Pilgrim Policy and the HIPAA Draft Security Rule, any PHI that is
transmitted using a public network must be encrypted. Web-based applications are configured to
use the Secure Socket Layer security software capabilities, and only a browser with support for
128-bit high encryption is acceptable under this policy. In addition, Harvard Pilgrim’s policy
requires the use of any encryption technology to be approved by the Harvard Pilgrim Information
Security Officer before implementation.

Harvard Pilgrim’s electronic trading partners wishing to interface their legacy systems and use file
transfer protocol (FTP) to transmit Electronic Data Interchange (EDI) transactions are supported by a
secure FTP server from SSH Communications. Transmissions are secured using public key encryption
and rely upon digital certificates to authenticate the server with the client software used by the provider.
Setup
Harvard Pilgrim does not send test or sample 835 transactions. All 835 transactions are “live” (i.e.,
actual production data). The decision to post 835 transactions to the payee’s test or production
accounts receivable system is solely the responsibility of the recipient.
The EDI team will assign a user ID, password and mailbox (folder) for file drop-off and
retrieval. The user ID allows access to the production environment. Harvard Pilgrim does not
set up 835 transactions in the payee’s test/development environment. When possible, an
existing production user ID, password and mailbox will be used.
For NEHEN recipients, Harvard Pilgrim will use the NEHEN-assigned values for Sender
(ISA06/GS02) and Receiver (ISA08/GS03) elements.
- HPHC is NEHEN003
For other recipients, the EDI team will assign the Sender (ISA06/GS02) and the Receiver
(ISA08/GS03) values. Where possible, the same identifiers will be used across all of the
provider’s transactions with Harvard Pilgrim. The values are negotiable, but, in general, are as
follows:
- ISA06 = HPHC0001 (Harvard Pilgrim is sending the 835 transaction)
- GS02 = HPHC0001B (Harvard Pilgrim is sending the 835 transaction)
- Receiver (ISA08/GS03)-----will be assigned but will be in the format HPHCxxxx where xxxx is
alphanumeric.
- Where possible, the same identifiers will be assigned to the provider for all of their
transaction exchanges with Harvard Pilgrim. For example, if a Provider is set up as
HPHC9AB3 (ISA06) and HPHC9AB31 (GS02) for the 837 transaction then HPHC9AB3 will
be used for ISA08 and HPHC9AB31 for GS03 in the 835 transaction. The transaction
determines when HPHC9AB3 is the Sender (837, 270, 276, etc.) and when it is the Receiver
(271, 277, 835, etc.).
Technical Requirements
Legacy Products
Harvard Pilgrim may send one 835/ERA file for each check that has been generated for a payee.
In the current operating environment (as of June 2002), checks and 835/ERA files are generated
weekly. A payee may receive up to six checks and ERA files (a medical and hospital check for
each Harvard Pilgrim insurance system). The 835 transaction does not include or support
pended claims or Negative Balance Reports.
Choice Plus and Options
Harvard Pilgrim may send one or many checks per 835/ERA file. In this new operating
environment (as of January 2007), checks and 835/ERA files are generated daily. With this new
generation process, Harvard Pilgrim is unable to separate files by payee number or site address
and deliver files to multiple recipients. Recipients who share a tax ID will need to identify one
mailbox to which the 835 files will be delivered.
This applies only to national plans Choice Plus and Options.

Retrieval Methods
HPHConnect—A provider retrieves the 835 ERA by downloading the file via the HPHConnect
File Transfer Agent (FTA).
NEHEN—Harvard Pilgrim delivers the 835 file to a specified directory on the Harvard Pilgrim
gateway. The Harvard Pilgrim gateway will be configured to automatically deliver the 835 file
to the receiver’s NEHEN gateway. It is the receiver’s responsibility to configure their NEHEN
gateway to accept the 835 file. Please contact your NEHEN representative to review your
gateway software version and configuration.
NEHENNet—A provider retrieves the 835 ERA by downloading the file from the NEHENNet
secure Web site.
Claims BBS and Secure FTP—Harvard Pilgrim delivers the 835 file to the Harvard Pilgrim
Claims Bulletin Board System (EMC PC) or secure FTP (File Transfer Protocol) server in a
specified directory. The provider can retrieve the file using an assigned user ID and password.
File-Naming Convention
The file-naming convention is: TSS_<ISA08>_<GS03>_CCYYMMDD_HHMM_835.txt
Where T = Type of Check (‘H’ for Hospital, ‘M’ for Medical or ‘C’ for combined)
SS = Insurance system that generated the 835/ERA
NS = Combined National Product
IS = Integrated Commercial
MI = Medicare, Medicare Wrap/Miscellaneous Commercial

<ISA08> = Assigned Receiver ID
<GS03> = Assigned Application Receiver ID
CCYYMMDD_HHMM = date and time the ERA file was created by Harvard Pilgrim
insurance systems.
Examples:
MIS_HPHC0001_HPHC0001B_20050119_1134_835.txt
HMI_NEHEN003_NEHEN003_20050131_1000_835.txt
CNS_HPHC0001_HPHC0001B_20070124_0920_835.txt
ERA Structure
Legacy Products
Harvard Pilgrim sends an 835 file for each type of check generated by each of its insurance
systems. There is only one ISA, GS segment per file. There may be one or more ST segments per
file. Each ST segment corresponds to a Payee/Check Number. The file is structured in the
following hierarchy:
ISA
GS
ST*835*nn
One check per Payee Number (BPR Segment) per insurance system
NM Loop 1000B—Payee Identification Qualifier XX the National Provider Identifier

REF Loop 1000B—Payee Additional Identification Qualifier TJ–Provider tax ID

number.
REF Loop 1000B —Payee Additional Identification Qualifier PQ the HPHC-assigned
payee number
Provider Loop 2000—LX segment is used to indicate the start of a provider’s claims.
Loop 2000 —TS3 contains the National Provider Identifier for the
subsequent group of claims.
Provider’s Claim Header (Loop 2100 CLP)
One or more Service lines with adjustment details. (Loop 2110 SVC)
Additional claims and corresponding service lines for the provider
A provider’s claims are grouped by Product
Repeat Loops for additional Providers’ claims and service lines
SE*
Repeat ST/SE Loops for additional Payee/Checks for this submitter.
ISA
GS
ST*835*nn
Multiple 835/ERAs maybe generated per check and tax identification number (BPR Segment)
NM Loop 1000B—Payee Identification Qualifier XX the National Provider Identifier
REF Loop 1000B—Payee Additional Identification Qualifier TJ – Provider tax ID
number.
Provider Loop 2000—LX segment is used to indicate the start of a provider’s claims.
Loop 2000 —TS3 contains the provider tax Identification number for the
subsequent group of claims.
NM Loop 2100 CLP—Patient Name Qualifier MI the Member Identification number
REF Loop 2100 CLP—Other Claim Related Identification Qualifier 1L the member group
number
Provider’s Claim Header (Loop 2100 CLP)
One or more Service lines with adjustment details. (Loop 2110 SVC)
Additional claims and corresponding service lines for the provider
A provider’s claims are grouped by employer group
Repeat Loops for additional Providers’ claims and service lines
SE*
This applies only to national plans Choice Plus and Options.
835 Content
The 835 transaction is compliant in both form and content. Harvard Pilgrim will continue to use
some non-standard revenue, CPT, HCPCS, location and explanation codes in its internal systems.
Any internal non-standard codes will be mapped to standard codes during creation of the 835
transaction. Paper EOPs will not change; they will continue to reflect values stored in Harvard
Pilgrim’s system, not the values in the 835 transaction. Refer to Conditional Data Requirements
for more information on the mapping process.
Member and provider demographic information is returned on the 835 transaction as it is stored
in Harvard Pilgrim’s system.

During claim data entry and claim adjudication, Harvard Pilgrim may bundle original claim lines
into one or more lines, add lines to the original claim, replace codes, translate codes to
nonstandard codes, and so on. In other words, the claim data stored in Harvard Pilgrim’s system
may not match the data on the original claim. Because the 835 transaction requires Harvard
Pilgrim to “tie back” data on the original claim to the adjudicated values, Harvard Pilgrim has
developed programs to match these values. Refer to Conditional Data Requirements for more
details on the matching processes.
In the cases listed below, Harvard Pilgrim is unable to return data from the original claim as
submitted by the provider. In these cases, Harvard Pilgrim will use only the data that is stored in
its system to generate claim information on the 835 transaction.
The original claim contains a non-standard revenue, CPT, HCPCS code, modifier or other
field necessary for the 835 transaction.
The original claim submitted charges (line and total) do not match the submitted charges in
the Harvard Pilgrim system.
Harvard Pilgrim may not have access to the original claim information.
Harvard Pilgrim, despite best efforts, is unable to match paid claim data with original claim
information.
If Harvard Pilgrim is unable to match paid claim information to data on the original claim, then
it will use only the data (mapped to standard codes if required) that is stored in its insurance
system to generate the claim information on the 835 file. It will assume that the data stored in its
insurance system matches the original claim information. The following fields will be impacted:
Submitted Charges (Monetary amount Loop 2100 CLP03)-----Contains the claim total
charged/submitted amount as stored in Harvard Pilgrim insurance systems.
Bill Type/Place of Service (Facility Code Value CLP08)-----Contains a Harvard Pilgrim location
code.
Service Date (Loop 2110 DTM)-----Contains the value(s) stored in the Harvard Pilgrim system.
As stated earlier, Harvard Pilgrim does not send test or sample 835 transactions. All 835
transactions are “live” or production data. The decision to post transactions to the Payee’s test or
production A/R system is solely the responsibility of the 835 recipient.
Unlike other transactions, testing and determination of production readiness is done solely by the
recipient of the 835 transaction. Once Harvard Pilgrim sets up a Provider/Payee to receive 835
transactions, Harvard Pilgrim sends production ERAs. Harvard Pilgrim does not generate test or
sample 835 transactions. Harvard Pilgrim will assist the 835 recipient with questions and clarifications
during the testing period. However, test plans, programming necessary to automatically post
payments to the A/R system and the decision to move from test to production are the responsibility
of the 835 recipient.
Additional REF Segments
Legacy Products
Harvard Pilgrim will return the payee National Provider Identifier in Payee Information (1000B)
N104 and the REF segment will contain the tax ID. Harvard Pilgrim will return an additional
REF segment containing the Harvard Pilgrim payee number for an unspecified time period.
Harvard Pilgrim will return the rendering provider NPI in Service Provider Name (2100)
NM109.


Choice Plus and Options member identifiers consist of a nine-character subscriber ID and six-
character group number. Harvard Pilgrim will return the subscriber ID in Patient Name Loop
(2100) where NM108 is “MI” and NM109 is the subscriber ID number. The group number will
be returned in Claim Payment Information Loop (2100) where REF01 is “1L” and REF02 is the
group number.
835 Recommendations
Harvard Pilgrim strongly recommends the following to 835 recipients:
Both technical and business staff should read and understand the first two sections (pp. 9–33)
of the 835 HIPAA Implementation Guide.
Business staff members who understand the current posting processes and rules for posting
payments from Harvard Pilgrim paper EOPs should work closely with technical staff to ensure
business rules are interpreted correctly in programs that automatically post the ERAs.
Technical and business staff should be familiar with HIPAA Claim Adjustment Group Codes
and HIPAA code set 139 (Health Care Claim Adjustment Reason Codes).
The 835 and Harvard Pilgrim’s paper EOP are different. It is important that business staff
understand the differences between Harvard Pilgrim internal codes and HIPAA standard
codes. For example, Harvard Pilgrim prints internal denial explanation codes on the paper
EOP. The 835 denial explanation codes are from the HIPAA standard code set 139.
Providers whose technical staff (or vendor) works closely with their business staff are the ones
who are most successful in implementing the 835 transaction.

Conditional Data Requirements __________________

Provider Level Adjustments (PLB)
In order to tie back the provider level adjustments to the claim/service lines, each PLB segment
contains the Harvard Pilgrim provider number in PLB01, which corresponds to the appropriate
LX/TS3 segment.
PLB03-1 value L6 interest payment adjustment
PLB03-1 value ZZ negative adjustment unused
PLB03-1 value CS negative balance unused
Interest Payments
On the paper EOP, interest payments (paid by Harvard Pilgrim to the provider) are included
with the claim’s service lines. For the 835 ERA transaction, Harvard Pilgrim follows the
Implementation Guide section 2.2.9. Interest payment service lines are removed from the claim
(CLP) section, the claim total is adjusted accordingly and the interest payments are included on
the PLB segment.
Matching Process
Harvard Pilgrim makes a best effort to match incoming claims information with the data in its
claims processing system. The approach is to match adjudicated lines in Harvard Pilgrim’s system
that are being paid on the 835 ERA with incoming data that was stored in a supplemental
database.
A new matching process was developed for Release 2.0. The matching process evaluates all of the
claim’s lines in Harvard Pilgrim’s system for the best match.
The following fields are used to match inpatient institutional claims:
Revenue codes—a selected set is used to match accommodations
Revenue codes/procedure codes—those codes that are not related to accommodations are used to
match ancillary services
The following fields are used to match outpatient and professional claims:
Service line adjudication status code
Amount charged
Date of service
Procedure code or revenue code
Units
Modifiers
Below are the cases that describe the relationship between incoming data and data stored in
Harvard Pilgrim’s claims processing system:
One to One—There is one line on the original claim and one line in Harvard Pilgrim’s system.
One to Many—There is one line on the original claim and multiple lines in Harvard Pilgrim’s system
(rare).
Many to One—There are multiple lines on the original claim and one line in Harvard Pilgrim’s
system, e.g. inpatient services and some outpatient services such as observation.

Many to Many—There are multiple lines on the original claim and multiple lines in the
Harvard Pilgrim system.
Please refer to the 835 content section. For examples of different cases, please refer to
Attachment B.
Claim & Service Line Adjustments

In general, Harvard Pilgrim’s claims processing system processes claims at a service line level. A
claim is not finalized until all service lines are in a payable state (set to pay or deny). Harvard
Pilgrim does not report a claim on the 835 ERA if any service line is pended.
Adjustments (Reversals & Corrections)

Once a claim has been paid it may be adjusted. Adjustments are performed at the service line
level and are done in pairs; a reversal of the paid/denied line followed by the corrected
payment/denial. One, some, or all service lines can be adjusted. Adjustments can also be made
through the addition of service line(s) to a claim.
On the paper EOP, adjustments (reversals and corrections) are grouped together under the claim
information. For the 835/ERA transaction, Harvard Pilgrim follows the Implementation Guide
section 2.2.8. Please refer to Attachment C for an example of a Reversal & Correction.
Mapping Non-Standard Codes

Providers are expected to submit standard codes. Although Harvard Pilgrim is moving toward
the use of standard codes in its internal system, it will continue to convert some of the standard
codes (e.g. location, revenue, CPT, HCPCS) to non-standard values for claims processing.
The 835 transaction can only contain standard codes. During outbound processing of the 835
transaction, Harvard Pilgrim must “re-map” non-standard internal codes to standard codes. If a
provider submits a non-standard code, such as 27A, Harvard Pilgrim will replace the incoming
data on the 835 with a standard value.
Harvard Pilgrim has designed cross-reference tables for mapping non-standard to standard
codes. Often, an internal non-standard code does not map one-for-one to a standard code. In these
cases, non-standard codes are mapped to a generic standard code that, most likely, does not
match the incoming standard code. Services that are most likely impacted by the use of non-
standard codes are inpatient, physical therapy, occupational therapy, and speech therapy.
Example 1
Provider submits a claim for inpatient services with the following revenue codes:
121 (Med/Surg Room & Board)
131 (Med/Surg Room & Board)
Harvard Pilgrim processes the claim as one service line with internal revenue code 02.
During 835 processing, 121 is returned in SVC06, 131 is also returned in SVC06 and 02 is
mapped to 120 in SVC01 for both lines.

Example 2
Provider submits a claim with the following code:
451 (ER/EMTALA)
Harvard Pilgrim processes the claim with internal code 18. During 835 processing, 451 is
returned in SVC06 and 18 is mapped to 450 in SVC01.
National Provider Identifier Defaults
LEGACY PRODUCTS
In those instances in which Harvard Pilgrim does not have the payee or rendering provider NPI
(from claim submitted or from provider outreach), we will report a default NPI of “9999999999.”
CHOICE PLUS AND OPTIONS
For Choice and Options products when Harvard Pilgrim does not have the payee or rendering
provider NPI (from claim submitted or from provider outreach), we will report the rendering
provider tax ID number.

835 Transaction Companion Guide (Release 2.0) Attachment A
Frequently Asked Questions _____________________
Q: The 835 file wraps and is difficult to read. Why doesn’t Harvard Pilgrim send a control
character at the end of each segment?
A: The segment terminator is a tilde (“~”) as specified in the ISA position 116, the character
following ISA16. Per the ANSI standard, the next character starts the GS segment; there is no
space for a control character, such as new line or carriage return. In order to view the file in a
more user-friendly format, we suggest replacement of the tilde with a NL or CR. This can be
done by the provider’s processing system or in Microsoft Word by using the Find/Replace
feature. (Go to Replace Tab, click on More, then click Special and select Manual Line Break.)
Q: If I receive an electronic 835, will I still receive a paper EOP?

A: At this time, Harvard Pilgrim will continue to send the paper EOP. Harvard Pilgrim may
eventually change this policy, at which time all 835 recipients would be notified.
Q: When are the 835 files generated?

A: For Legacy products, Harvard Pilgrim produces checks on a weekly basis. In general, the 835
files are available by close-of-business on Wednesdays.
For Choice Plus and Options, Harvard Pilgrim produces checks daily. In general, the 835
files are available the next business morning.
Q: How many 835 files can I receive?

A: Currently, for each submitter, there may be up to six checks and six files. This corresponds to
a medical check and hospital check for each of Harvard Pilgrim’s three claims processing
systems.
Q: What are the new 835 files with CNS naming convention?
A: These are 835 files for claims submitted for Choice Plus and Options members. Checks and
835 files for Choice and Options members are generated at the member employer group
level, then aggregated to the servicing provider’s tax ID number.
Q: Why are the claims in the 835 file in a different order than on the paper EOP?
A: Two separate processes generate the 835 and paper EOP. Both processes group claims by
product, but the order of the claims may be different.
Q: Why don’t the claims in the 835 appear to match the claims in the paper EOP?
A: There are several reasons why the two may not match; examples include:
Harvard Pilgrim interest payments are in the PLB segment in the 835 ERA, so the sort
order of claims may be different.
The paper EOP groups certain categories together such as Risk/Discount that are broken
out in the 835 ERA.

835 Transaction Companion Guide (Release 2.0) Attachment A
Reversals and corrections (adjustments) are displayed differently in the 835 ERA. The 835
ERA displays HIPAA codes, whereas the paper EOP displays Harvard Pilgrim’s proprietary
codes.
The paper EOP displays internal explanation codes and other values such as Revenue and
CPT codes; the 835 ERA maps these values to HIPAA standard codes.
Q: Why did I receive a 9999999999 as my NPI in the 835 file?

A: Harvard Pilgrim reports a value of “9999999999” when we are unable to identify the payee or
rendering provider NPI to report in the 835 file. Check that you have accurately reported
your NPIs to Harvard Pilgrim.
Q: How do I know if a line has been denied?

A: Harvard Pilgrim uses the Health Care Claim Adjustment Reason Codes (Code Set 139). The
code description indicates if an adjustment is a deny code. Attachment D contains the cross-
reference of Harvard Pilgrim deny codes to the standard code set. This cross-reference may
change as codes are added/deleted by Harvard Pilgrim.
Q: How do I calculate the allowed amount?

A: Please refer to Attachment E.
Q: How do I recognize an encounter (capitated claim)?
A: Harvard Pilgrim will identify an encounter at the line level. Each claim line that includes an
encounter service will be reported with Adjustment Group code ‘‘CO’’ and Adjustment
Reason Code ‘‘24’’ (Fee for Service). The value of this claim line will be the fee for service
equivalent of the capitated service.
Q: How do I recognize a claim for which Harvard Pilgrim was the secondary payer?
A: If condition is a paid claim and Harvard Pilgrim is the secondary payer, then the claim will
be reported with:
Claim Status Code “2” in the CLP02 segment,
Adjustment Group Code “OA" with Adjustment Reason Code “23” indicating COB, and
Adjustment Group Code “OA" with Adjustment Reason Code “45” indicating the balance
paid to charged amount for the COB claim.
Q: How do I recognize a claim that has been denied by Harvard Pilgrim?

A: Harvard Pilgrim will define a ‘‘Denied Claim’’ as a claim on which the last version of all
claim lines is denied. The claim will be reported with a Claim Status Code of ‘‘4’’ in the
CLP02 segment.

835 Transaction Companion Guide (Release 2.0) Attachment B
Matching Examples ______________________________

One to One
Example
Original claim and adjudicated claim have one service line.

Adjudicated procedure code matches submitted procedure code.
Original and adjudicated procedure codes are standard codes.
Incoming Claim
Claim# 021230X11234
Line Revenue Proc # Amount Charged Unit
1 70450 168.00 1
Paper EOP
Claim# 021230X11234 Total charged: 168.00 Paid: 43.40

Line Proc # Count Amount Amount CoPay Deduct Discount
Charged Paid
0100 70450 1 168.00 43.40 0 0 0
Electronic 835 File
ERA programming format for the submitted claim and paper EOP above.
Line Descriptions
Claim header lines CLP* PCT123*1*168*43.4*0*16*021230X11234*22

NM1*IL*1*InsurerLastName *InsurerFirstName MI****HP078877400
NM1*82*1*DrLastName*DrFirstName****XX*1239874560
Detail description SVC*HC:70450*168*43.4**1

Service line 1 DTM*472*20040825
CAS*PI*45*124.6
One to Many
Example 1
Original claim came in with one service line with a count of three.
Harvard Pilgrim denies the service line with the count of three. The procedure then is split into
two lines. One line pays, the other denies.
Incoming claim
Claim # 021230X11234
1 0311 88173 327 3

Paper EOP
Claim # 021230X11234 Total charged: 327.00 Paid: 72.45

Line Proc # Count Amount Charged Amount Paid Copay Deductible Discount
1 88173 3 0 0 0 0 0
2 88173 1 109.00 72.45 0 0 0
3 88173 2 218.00 0 0 0 0
Electronic 835 File
Line Descriptions CLP* PCT123*1*327*72.45*0*HM*021230X11234*13
Claim header lines NM1*QC*1*PatientLastName *PatientFirstName MI****HP078877401
NM1*IL*1*InsurerLastName *InsurerFirstName MI****HP078877400
NM1*82*1*ProvLastName*ProvFirstName****XX*1239874560
Detail description SVC*HC:88173*327*72.45*0311*3**1

CAS*CO*45*254.55
Example 2
Original claim came in with a service and a count of two.

Harvard Pilgrim splits the claim into two lines.
Incoming claim
Claim # 021230X11234
1 73510 120 2
Paper EOP
Claim # 021230X11234 Total charged: 120.00 Paid: 0

Line Proc # Count Amount Amount CoPay Deductible Discount
Charged Paid
1 73510 2 0 0 0 0 0
2 73520 1 120.00 0 0 0 0
Electronic 835 File
Line Descriptions CLP* PCT123*1*120*0*0*HM*021230X11234*11
NM1*82*1*DrLastName*DrFirstName****XX*1239874560
Detail description SVC*HC:73520*120*0**1*HC:73510*2

CAS*CO*24*47.3
CAS*CO*45*72.7
REF*6R*12297917 -01

Many to One
Example 1
Original claim has two service lines with standard codes.

Harvard Pilgrim bundled the service lines into one line and paid using a standard code.
Incoming Claim
Claim# 021230X11234
Line Revenue Proc # Amount Charged Count
1 0450 60 1
2 0450 99282 234 1
Paper EOP

1 18 2 294.00 85.00 75.00 0 0
Electronic 835 File
The internal procedure code 18 is mapped to revenue code 0450.

NM1*82*1*ProvLastName*ProvFirstName**** XX*1239874560
Detail Description
SVC*NU:0450*60*85**2**1
Service line 1
DTM*472*20041214
CAS*PR*3*75
CAS*CO*45*134
CAS*OA*94*-234
Service line 2 SVC*NU:0450*234*0**2**1

DTM*472*20041214
CAS*CO*97*234
Example 2
Outpatient claim came in with multiple service lines and standard codes.
Harvard Pilgrim adjudicated as one service line with a standard code.
Incoming Claim
Claim# 021230X11234
0001 0250 155.22 6
0002 0301 83021 15 1
0003 0305 85027 23 1
0004 0305 85045 13 1
0005 0450 99285 1106 1
0006 0460 94760 62 1
0007 0762 99218 819 13
0008 0762 99218 1197 19

Paper EOP

1 762 32 3390.22 1288.00 0 2102.22 0
Electronic 835 File
Line Descriptions
Claim header line CLP* PCT123*1*3390.22*1288*0*HM*021230X11234*13
NM1*QC*1*PatientLastName *PatientFirstName MI****HP078877401
Detail description SVC*NU:0762*819*1288**32**13

CAS*CO*45*2102.22
CAS*OA*94*-2571.22
Service line 2 SVC*NU:0762*155.22*0**32*NU:0250*6

DTM*472*20041207
CAS*CO*97*155.22
Service line 3 SVC*NU:0762*15*0**32*NU:0301*1

DTM*472*20041207
CAS*CO*97*15

DTM*472*20041207
CAS*CO*97*23

DTM*472*20041207
CAS*CO*97*13

DTM*472*20041207
CAS*CO*97*1106

DTM*472*20041207
CAS*CO*97*62
Service line 8 SVC*NU:0762*1197*0**32**19

DTM*472*20041207
CAS*CO*97*1197

Many to Many
Typically, a many-to-many match is a combination of all possible cases (i.e., one-to-one, one-to-
many, and many-to-one).
Example 1
Incoming Claim
Claim# 021230X11234
0001 0170 568 2
0002 0250 6.74 1
0003 0300 156 2
0004 0320 533 3
Paper EOP

Line Proc # Count Amount Amount Copay Deductible Discount
Charged Paid
0100 06 2 568.00 1054.83 0 0 0
0200 73B 1 695.74 0 0 0 0
Electronic 835 File
The original service lines 2, 3 and 4 are considered combined while service line 1 is adjudicated
separately. The internal code 06 and 73B are mapped to standard codes 0170 and 0240
respectively.
Line Descriptions CLP* PCT123*1*1263.74*1054.83*0*13*021230X11234*11***0629
Detail description
Service line 1 SVC*NU:0170*568*1054.83**2
DTM*150*20041204
DTM*151*20041206
CAS*CO*94*-486.83
Service lline 2 SVC*NU:0240*6.74*0**1*NU:0250

DTM*150*20041204
DTM*151*20041206
CAS*OA*94*-689
CAS*CO*45*695.74

DTM*150*20041204
DTM*151*20041206
CAS*CO*97*156

DTM*150*20041204
DTM*151*20041206
CAS*CO*97*533

Example 2
Incoming Claim
Claim# 021230X11234
0100 0300 82374 18 1
0200 0300 82435 17 1
0300 0300 82565 20 1
0400 0300 82947 15 1
0500 0300 83735 49 1
0600 0300 84132 17 1
0700 0300 84295 18 1
0800 0300 84520 15 1
0900 0761 99201 43 1
Paper EOP

Line Proc # Count Amount Amount CoPay Deductible Discount
Charged Paid
0100 82374 1 0 0 0 0 0
0200 82435 1 0 0 0 0 0
0300 82565 1 20.00 16.00 0 0 4.00
0400 82947 1 15.00 12.00 0 0 3.00
0500 83735 1 49.00 39.20 0 0 9.80
0600 84132 1 0 0 0 0 0
0700 84295 1 0 0 0 0 0
0800 84520 1 15.00 12.00 0 0 3.00
0900 99201 1 43.00 0 0 0 0
1000 80051 1 70.00 56.00 0 0 14.00
Electronic 835 File
The original service lines are 1, 2, 6, and 7. The individual lines are not paid, but are bundled
into an additional service line, 10.

Line Descriptions CLP* PCT123*1*212*135.2*0*HM*021230X11234*13

Detail description
Service line 1 SVC*HC:82565*20*16*0300*1
DTM*472*20040822
CAS*CO*131*4

DTM*472*20040822
CAS*CO*131*3
Service line 3 SVC*HC:83735*49*39.2*0300*1

DTM*472*20040822
CAS*CO*131*9.8

DTM*472*20040822
CAS*CO*131*3

DTM*472*20040822
CAS*PI*B16*43
Service line 6 SVC*HC:80051*18*56*0300*1*HC:82374

DTM*472*20040822
CAS*CO*131*14
CAS*OA*94*-52

DTM*472*20040822
CAS*CO*97*17

DTM*472*20040822
CAS*CO*97*17

DTM*472*20040822
CAS*CO*97*18

835 Transaction Companion Guide (Release 2.0) Attachment C
Reversal and Correction __________________________

Example
Incoming Claim
Claim# 021230X11234
0001 0300 G0001 11 1
0002 0305 85027 38 1
0003 0305 85610 130 2
0004 0490 46600 28 1
0005 0510 99213 87 1
Paper EOP

Line Proc #/Rev Count Amount Amount Paid Copay Deductible
Charged
0100 G0001 1 11.00 0 0 0
0200 85027 1 38.00 0 0 0
0300 85610 2 130.00 0 0 0
0400 46600 1 28.00 333.00 0 0
0500 510 1 87.00 0 0 0
Electronic 835 File

Claim header details NM1*QC*1*PatientLastName *PatientFirstName MI****HP078877401
Detail description
Service line 1 SVC*HC:G0001*11*0*0300*1

DTM*472*20040128
CAS*CO*97*11

DTM*472*20040128
CAS*CO*97*38

DTM*472*20040128
CAS*CO*97*130

DTM*472*20040128
CAS*CO*94*-305
Service line 5 SVC*NU:0510*87*0**1

DTM*472*20040128
CAS*CO*97*87
After the first payment, service line 4 was adjusted by neutralizing the first paid amount $333.00.
A new payment of $28.00 is made.
Paper EOP will only have reversal and correction service lines.
Electronic payment advice will have two entries for the same claim. The first will be for reversal
of previous payment; the second will be for corrected payment. The first claim will have all the
service lines sent earlier with negative charge amount and negative amount paid. The second
claim will also have all the service lines including the adjusted service lines.

835 Transaction Companion Guide (Release 2.0) Attachment C
Paper EOP
Claim# 021230X11234 Total charged: 0 Paid: -305.00

Line Proc # Count Amount Charged Amount Paid COB Risk
0401 46600 1 -28.00 -333.00 0 0
0402 46600 1 28.00 28.00 0 0
Electronic 835 File (Reversal)
Line Descriptions CLP* PCT123*22*-294*-333*0*HM*021230X11234*13

Detail description
Service line 1 SVC*HC:G0001*-11*0*0300*-1

DTM*472*20040128
CAS*CR*97*-11
Service line 2 SVC*HC:85027*-38*0*0305*-1

DTM*472*20040128
CAS*CR*97*-38
Service line 3 SVC*HC:85610*-130*0*0305*-2

DTM*472*20040128
CAS*CR*97*-130
Service line 4 SVC*HC:46600*-28*-333*0490*-1

DTM*472*20040128
CAS*CR*94*305
SVC*NU:0510*-87*0**-1
CAS*CR*97*-87
Electronic 835 File (Correction)
Line Descriptions CLP*PCT123*1*294*28*0*HM*021230X11234*13

Detail description
Service line 1 SVC*HC:G0001*11*0*0300*1

DTM*472*20040128
CAS*CO*97*11

DTM*472*20040128
CAS*CO*97*38

DTM*472*20040128
CAS*CO*97*130

DTM*472*20040128
Service line 5 SVC*NU:0510*87*0**1

DTM*472*20040128
CAS*CO*97*87

835 Transaction Companion Guide (Release 2.0) Attachment D
Deny Codes ______________________________________

Claim Adjustment Reason Codes 16, 17, 96, 125, A1 are generic in nature and are used as defaults
when a more descriptive Adjustment Reason Code is not available. As Mandated, when used
Harvard Pilgrim will return a compliant Remittance Remark Code from code source 411.
Adjustment Group Codes may be different for contracted and non-contracted Harvard Pilgrim
providers. Harvard Pilgrim recommends that 835 recipients determine/post denied charges based
on the 835 Adjustment Reason Code not on Harvard Pilgrim mapped values. Harvard Pilgrim
may, at any time, re-map, add or delete codes.
Harvard Pilgrim Contracted/ 835 Claim Adjustment 835 Claim Adjustment
Code Non-contracted Group Code Reason Code
07 CO 97
25 PR 96
30 PR 38
32 PR B8
33 CO 62
34 PR 96
35 PR 96
36 Contracted CO 62
36 Non-contracted PI 62
37 PR 62
38 CO 38
39 PR 62
40 PR 62
41 PR 26
42 PR 31
43 PR 22
44 PR 19
45 PR 22
46 Contracted CO 29
47 Contracted CO 18
48 CO 97
49 Contracted CO 54
50 PR 50
51 PR 50
52 PR 56
53 Contracted CO 56
53 Non-contracted PR 56
54 Contracted CO 11
55 Contracted CO 62
56 PR 35
57 CO B5
58 PR 96


59 CO 38
60 PR 62
61 CO 38
62 Contracted CO 38
63 CO 38
64 Contracted CO 112
65 Contracted CO 16
66 PR 27
67 Contracted CO 109
67 Non-contracted PR 109
68 PR 38
69 PR 38
70 PR 38
71 PR 96
72 PR 96
73 CO 52
94 PR 20
ad Contracted CO 138
ad Non-contracted PI 138
AJ Contracted CO 15
AJ Non-contracted PR 15
an Contracted CO 138
an Non-contracted PI 138
B1 Contracted CO 16
B1 Non-contracted PR 16
B9 PR 16
BE Contracted CO 137
BE Non-contracted PI 137
BV Contracted CO B11
BV Non-contracted PI B11
CA PR 109
CD Contracted CO 62
CD Non-contracted PI 62
CE Contracted CO 150
CE Non-contracted PR 150
CF Contracted CO 140
CF Non-contracted PI 140
CH PR 96
CN CO 52
CP Contracted CO 125
CP Non-contracted PI 125
CR Contracted CO B7
CR Non-contracted PI B7
CV Contracted CO 140
CV Non-contracted PI 140


CW PR 96
CY Contracted CO 62
CY Non-contracted PI 62
CZ Contracted CO 109
CZ Non-contracted PI 109
D1 Contracted CO 16
D1 Non-contracted PI 16
d1 Contracted CO 11
d1 Non-contracted PR 11
D2 Contracted CO 16
d2 Contracted CO 16
d2 Non-contracted PR 16
D6 Contracted CO 16
D7 PR 40
DB Contracted CO 16
DB Non-contracted PI 16
DD Contracted CO 96
DD Non-contracted PI 96
DE Contracted CO 47
DE Non-contracted PI 47
DG Contracted CO A8
DG Non-contracted PI A8
DH Contracted CO B7
DH Non-contracted PI B7
dm CO 45
DR Contracted CO A8
DR Non-contracted PI A8
DU Contracted CO 16
DU Non-contracted PI 16
DV Contracted CO 16
DV Non-contracted PI 16
DY Contracted CO 16
DY Non-contracted PI 16
EA Contracted CO 62
EA Non-contracted PI 62
EB PR 119
EC Contracted CO 29
EC Non-contracted PI 29
ED Contracted CO B8
ED Non-contracted PI B8
EM Contracted CO B18
EM Non-contracted PI B18
EN Contracted CO B8
EN Non-contracted PI B8
ET Contracted CO 52
ET Non-contracted PI 52


EV PR 109
FD Contracted CO 18
FD Non-contracted PR 18
fd Contracted CO 29
fd Non-contracted PR 29
FE Contracted CO 29
FE Non-contracted PI 29
FF CO 108
FG Contracted CO 16
FG Non-contracted PI 16
FK Contracted CO 16
FK Non-contracted PI 16
FL Contracted CO 109
FL Non-contracted PI 109
FM Contracted CO 50
FM Non-contracted PI 50
FN PR 50
FO Contracted CO 16
FO Non-contracted PI 16
FP Contracted CO 16
FP Non-contracted PI 16
FQ Contracted CO 50
FQ Non-contracted PI 50
FR PR 29
FZ Contracted CO 4
FZ Non-contracted PR 4
G6 PR 20
G7 Contracted CO 29
G7 Non-contracted PI 29
G8 Contracted CO 16
G8 Non-contracted PI 16
G9 PR 17
GC PR 21
GG Contracted CO 16
GG Non-contracted PI 16
GH Contracted CO 109
GH Non-contracted PI 109
GP Contracted CO 125
GP Non-contracted PI 125
GR CO A8
GS CO A2
H1 CO 97
H2 CO 97
H8 Contracted CO 97
H8 Non-contracted PI 97
HA CO B18
HB CO 16
HC CO 4


HD CO 16
HE CO 16
HF CO 16
HH CO B18
HJ CO 16
HL CO B18
HM Contracted CO 4
HM Non-contracted PI 4
HN CO 16
HO CO 16
hs CO A1
HT CO 16
HU CO 15
I2 Contracted CO 29
I2 Non-contracted PI 29
IB CO 16
ib CO 135
Ib Contracted CO B18
Ib Non-contracted PI B18
ID Contracted CO 47
ID Non-contracted PI 47
IN Contracted CO 16
IN Non-contracted PI 16
IP Contracted CO B18
IP Non-contracted PI B18
IS CO 16
IT Contracted CO 16
IT Non-contracted PI 16
IV Contracted CO B18
IV Non-contracted PI B18
IX CO 16
J1 PR 109
J2 PR 109
J3 PR 109
J4 PR 109
J5 PR 109
JJ Contracted CO 109
JJ Non-contracted PI 109
JR PR 27
KG Contracted CO 31
KG Non-contracted PR 31
lb Contracted CO 4
lb Non-contracted PI 4
LE Contracted CO 125
LE Non-contracted PI 125
LY Contracted CO 6
LY Non-contracted PI 6
M4 Contracted CO 136


M4 Non-contracted PI 136
M7 Contracted CO 96
M9 Contracted CO 109
MM Contracted CO 96
MM Non-contracted PI 96
MR Contracted CO 4
MR Non-contracted PI 4
NA Contracted CO 62
NA Non-contracted PI 62
NE PR 96
NH Contracted CO 109
NH Non-contracted PR 109
NI PR 30
NN Contracted CO B18
NN Non-contracted PI B18
NP Contracted CO B16
NP Non-contracted PI B16
NS PR 11
NY CO 62
OB CO 16
OI CO 60
OP Contracted CO 16
OP Non-contracted PI 16
OX Contracted CO 59
OX Non-contracted PI 59
Pg OA B13
PU CO 16
Pv Contracted CO 125
Pv Non-contracted PI 125
QA Contracted CO B11
QA Non-contracted PI B11
QS Contracted CO A1
QS Non-contracted PI A1
QW Contracted CO 16
QW Non-contracted PI 16
RC Contracted CO 10
RC Non-contracted PI 10
RE Contracted CO 9
RE Non-contracted PI 9
RF Contracted CO 10
RF Non-contracted PI 10
RH Contracted CO 9
RH Non-contracted PI 9
RI Contracted CO 7
RI Non-contracted PI 7
RK Contracted CO 6


RK Non-contracted PI 6
RQ Contracted CO B7
RQ Non-contracted PI B7
RV Contracted CO 11
RV Non-contracted PI 11
RY Contracted CO B7
RY Non-contracted PI B7
S0 Contracted CO 52
S0 Non-contracted PI 52
SD Contracted CO 97
SD Non-contracted PI 97
SF Contracted CO 62
SF Non-contracted PI 62
SG PR 96
SH Contracted CO 16
SH Non-contracted PI 16
SI Contracted CO 38
SI Non-contracted PI 38
SJ Contracted CO 97
SJ Non-contracted PI 97
SK PR 26
SL PR 22
SM PR 22
SN Contracted CO 18
SN Non-contracted PR 18
SO PR 35
SP Contracted CO 143
SP Non-contracted PR 143
SQ PR 27
SV Contracted CO 18
SV Non-contracted PI 18
T1 PR 50
T3 Contracted CO 39
T3 Non-contracted PI 39
T4 Contracted CO 39
T4 Non-contracted PR 39
TD Contracted CO 16
TD Non-contracted PI 16
TF Contracted CO A1
TF Non-contracted PI A1
TU Contracted CO 59
TU Non-contracted PI 59
TY Contracted CO 59
TY Non-contracted PI 59
UN Contracted CO 31
UN Non-contracted PI 31
VB PR 96
VC Contracted CO 29


VC Non-contracted PI 29
VD OA B13
VG Contracted CO 16
VG Non-contracted PI 16
VH CO 109
VJ OA B13
VL OA B13
VN OA B13
VO Contracted CO 109
VO Non-contracted PI 109
WD Contracted CO 96
WD Non-contracted PI 96
XA Contracted CO B5
XA Non-contracted PI B5
XB Contracted CO 62
XB Non-contracted PI 62
XE Contracted CO 97
XE Non-contracted PI 97
XH PR 31

835 Transaction Companion Guide (Release 2.0) Attachment E
Calculation of Allowed Amount__________________
CASE A: If the Service line is Not Denied and No Miscellaneous Adjustment
Adjustment Adjustment Definition Amisys Field

Group Code Reason Code
PR 1 Deductible AMTDeduct
PR 2 Coinsurance AMTCoins
PR 3 Copay AMTCoPay
OA 23 COB (AMTPAY-M + AmtTPP–Apply)
CO 104 Risk AMT Risk
CO 131 Discount AMT Discount
CO 24 Fee For Service AMT–FFS
CO/PI 45 Balance Paid to N/A–Balance to Charged Amount if payment
Charged Amount is less than submitted charge
CO/PI 94 Balance Paid to N/A–Balance to Charged Amount if payment
Charged Amount is greater than submitted charge
OA -45 Balance Paid to N/A–Balance to Charged Amount if payment
Charged Amount for is less than or greater than submitted charge
COB Claim for COB claim
CO = Contracted; PI = Not Contracted

Allowed = Amount Paid + Deductible + Coinsurance + Copay + COB + Risk + Discount + Fee For Service.
Amount Paid is SVC03
CASE B: If the Service line is Denied, then Allowed cannot be computed.
If the Adjustment Group & Reason code combination is on the Deny List (Attachment D), not one of those in
Case A or Case C, then this is a denied service line.
CASE C: Miscellaneous Adjustment. Some Service lines have a Miscellaneous Adjustment. The line
was adjusted/manually priced. Allowed Amount cannot be calculated.
Adjustment Code Definition

Category
OA A2 Miscellaneous Adjustment------Claim
has been adjusted/manually priced.
Allowed Amount cannot be
calculated.

835 Transaction Companion Guide (Release 2.0) Attachment F
Seg ID Segment/Description Loop SEQ Max NOTES Valid Values Provider Paper
ID Req Seq EOP Fields
Use
Fields shaded in gray will not be sent by HPHC
ISA Interchange Control Header R 1

ISA01—Author Info Qualifier R “00”
ISA02—Author Information R bb
ISA03—Security Info Qual R “00”
ISA04—Security Information R bb
ISA05—Interchange ID Qual R Actual sender name ZZ
ISA06—Interchange Sender ID R ’HPHC’s identification, as per
trading partner agreement.
Refer to Companion Guide.
ISA07—Interchange ID Qual R ZZ
ISA08—Interchange Receiver ID R Receiver’s ID based on
trading partner’s agreement
ISA09—Interchange Date R DATE (YYMMDD)
ISA10—Interchange Time R Time (HHMM)
ISA11—Inter Ctrl Stand Ident R HIPAA version U
ISA12—Inter Ctrl Version Num R “00401”
ISA13—Inter Ctrl Number R EDI compliance value EDI-Assigned
ISA14—Ack Requested R 0 0
ISA15—Usage Indicator R HPHC will always assign P P
since data will be from the
production systems. It is the
provider’s responsibility to
post to their test or
production environment.
ISA16—Component Elem R 105th byte of ISA line :
Sepera
Segment Terminator R Tilde ~ ~
(Data Element Separator) R 4th byte of ISA line *
GS Functional Group Header R 1

GS01—Functional ID Code R HP
GS02—Application Send’s R HPHC’s identification, as per
Code trading partner agreement.
Refer to Companion Guide.
GS03—Application Rec’s Code R Receiver’s ID based on
trading partner agreement.
GS04—Date R Date (CCYYMMDD)
GS05—Time R Time (HHMM)
GS06—Group Ctrl Number R EDI-Assigned
GS07—Responsible Agency R X
Code
GS08—Ver/Release ID code R 004010X091A1

Use
ST Transaction Set Header R 1 Each ST/SE loop

corresponds to a
Payee/Check
43 ST01—TS ID Code R 835
ST02—TS Control Number R EDI-Assigned
BPR Payment Order/Remittance R 1

Advice
44 BPR01—Transaction Handle R Remit information only or I/H
Code notification only
BPR02— Monetary Amount R Total amount of the check HPHC-supplied On the cover
sheet
BPR03—Credit/Debit Flag Code R Credit C
BPR04— Payment Method R Check only. Set to NON if CHK / NON
Code check amount is $0.00
BPR05—Payment Format Code S N/A
BPR06—DFI ID No Qualifier S N/A
BPR07—DFI ID Number S N/A
BPR08—Acct Number Qualifier S N/A
BPR09—Account Number S N/A
BPR10—Originating Company S N/A
ID
BPR11—Originating Co Code S N/A
BPR12—DFI ID No Qualifier S N/A
BPR13 —DFI ID Number S N/A
BPR14—Acct Number Qualifier S N/A
BPR15—Account Number S N/A
BPR16—Date R Post date of check HPHC-supplied Post Date
(CCYYMMDD )
TRN Reassociation Trace Number R 1

52 TRN01—Trace Type Code R 1
TRN02— Reference Ident R Check number HPHC-supplied Check Number
Note: If the amount of the
check would have been $0,
HPHC does not issue a check
number. In this case TRN02
will begin with NOCHK
followed by additional
information to make the
value unique.
TRN03—Originating Company R HPHC IRS number 1<HPHC Tax
ID ID>
TRN04— Reference Ident S HPHC
CUR Foreign Currency Info S Not used

Use
REF Receiver Identification S 1 Not used
REF Version Identification S 1 Not used
DTM Production Date S 1 Not used
N1 Payer Name 1000A R 1

62 1000A -N101—Entity Code R PR
1000a—N102—Name S Payer name HPHC
1000A—N103—ID Code S N/A
Qualifier
1000A—N104 —ID Code S N/A
N3 Payer Address 1000A R 1

64 1000A—N301—Address R HPHC-supplied
Information
1000A—N301—Address S HPHC-supplied
Information
N4 Payer Geography 1000A R

65 1000a—N401—City Name R HPHC-supplied
1000a—N402—State or Prov R HPHC-supplied
Code
1000A—N403—Postal Code R HPHC-supplied
REF Additional Payer Identifier 1000A S Not used
PER Payer Contact Information 1000A S 1

69 1000A—PER01—Contact Funct R CX
Code
1000a—PER02—Name S N/A
1000A—PER03—Comm S Sending telephone number TE
Number Qual
1000a—PER04—Comm S Telephone number HPHC-supplied
Number
1000A—PER05—Comm S N/A
Number Qual
1000a—PER06—Comm S N/A
Number
1000A—PER07—Comm S N/A
Number Qual
1000a—PER08—Comm S N/A
Number

Use
PAYEE INFORMATION
N1 Payee Name 1000B R 1
72 1000B—N101—Entity Code R PE
1000b—N102—Name S Payee name—who the check Payee Name
is for/ as stored in HPHC
1000B—N103—ID Code Qual R XX

1000B—N104—ID Code R National Provider Identifier National
Provider
Identifier
N3 Payee Address 1000B S 1

74 1000B—N301—Address Info R As contained on HPHC
records
1000B—N301—Address Info S As contained on HPHC
records
N4 Payee Geography 1000B S

75 1000b—N401—City R As contained on HPHC
records
1000b—N402—State R As contained on HPHC
records
1000B—N403—Postal Code R As contained on HPHC
records
1000b—N404—Country Code S N/A
REF Payee Additional S

Identification
77 1000b—REF01-Reference Ident R Payee identification PQ
Qual Tax ID Number TJ
1000b—REF02-Reference Ident R Payee number associated
with this check
Tax ID Number
Provider Summary Information

LX Header Number 2000 S LX before each provider
and before each product
79 2000—LX01—Assigned R Increments by 1
Number starting at 0
TS3 Provider Summary 2000 S

Information
80 2000—TS301—Reference Ident R National Provider Identifier
2000—TS302—Facility Code R Location Code

Use
2000—TS303—Date R Set to the last day of the
year—ex. 20011231. HPHC
will not supply the provider’s
fiscal period end
(CCYYMMDD)
2000—TS304—Quantity R Total number of claims for
this provider
2000—TS305—Monetary R Total charge amount for all
Amount claims. This is what is on
record with HPHC; may not
be the same as submitted by
the provider. Refer to
Companion Guide.
2000—TS306 S Medicare Use Only
TS2 Transaction Supplemental S Not used

Statistics
Claim Information
CLP Claim Level Data 2100 R 1

Use
89 2100—CLP01—Claim Submt R Patient account number. If Account
Identifier Patient account number has Number
an * ~ or : there is a conflict
with 835 delimiters and the
character will be replaced
with a space.
2100—CLP02—Claim Status R HPHC returns HIPAA valid 1, 2, 4 or 22
Code claim status codes 1,2, 4 &
22
2100—CLP03—Monetary R Total charges submitted. May Total of claim
Amount not be the same as submitted CHARGED lines
by the provider. Refer to
Companion Guide.
2100—CLP04—Monetary R Total for this claim that HPHC HPHC-supplied Total of claim
Amount paid—less interest payment PAYMENT fields.
Paper EOP
includes interest
payment.
2100—CLP05—Monetary S Patient Responsibility Amount HPHC-supplied
Amount
2100—CLP06—Claim File Ind R Product Code HPHC-supplied Product (Name)
Code
2100—CLP07—Reference Ident S HPHC’s internal claim number HPHC-supplied Claim Number
2100—CLP08—Facility Code S Facility Code Value
2100—CLP09—Claim Freq S N/A
Type Code
2100—CLP10 S N/A
2100—CLP11—DRG Code S DRG as stored at HPHC— DRG#
Inpatient only
2100—CLP12 S N/A
2100—CLP13 S N/A
CAS Claim Adjustment 2100 S 1 With the exception of No need to

positive adjustments, send this
HPHC will not send Claim segment at
Level Adjustments. HPHC claim level
will send service level since there
adjustments only. Refer to will be no
the HPHC Companion claim level
Guide for Corrections & adjustment
Reversals.
95 2100—CAS01 R
2100—CAS02 R
2100—CAS03 R
2100—CAS04 S
2100—CAS05 S
2100—CAS06 S
2100—CAS07 S
2100—CAS08 S

Use
2100—CAS09 S
2100—CAS10 S
2100—CAS11 S
2100—CAS12 S
2100—CAS13 S
2100—CAS14 S
2100—CAS15 S
2100—CAS16 S
2100—CAS17 S
2100—CAS18 S
2100—CAS19 S
NM1 Patient Name 2100 S 1

102 2100—NM101—Entity ID Code R Patient indicator QC
2100—NM102—Entity Type R Person 1
Qualifier
2100—NM103— Name R Patient last name from HPHC Patient Name
Last/Org Name records
2100—NM104— Name First S Patient first name from HPHC Patient Name
records. May include middle
initial.
2100—NM105—Name Middle S N/A
2100—NM106—Name Prefix N N/A
2100—NM107—Name Suffix S N/A
2100—NM108— ID Code S Member ID indicator MI
Qualifier
2100—NM109—ID Code S Member ID claim was paid HPHC-supplied ID Number
“against.” May not match
member ID sent by the
provider.
NM1 Subscriber/Insured Name 2100 S 1 If patient isn’t the HPHC- Not on paper
subscriber (patient is not supplied EOP
the 00 member)
2100—NM101—Entity ID Code R Insured/Subscriber IL
2100—NM102—Entity Type R Person 1
Qualifier
2100—NM103— Name R Subscriber last name from
Last/Org Name HPHC records
2100—NM104— Name First S Subscriber first name from
HPHC records. May include
middle initial.

Use
2100—NM108— ID Code S Member ID indicator MI
Qualifier
2100—NM109—ID Code S Subscriber member ID
NM1 Corrected Patient/Insured 2100 S Not used

Name
NM1 Service Provider Name 2100 S 1 Not on paper

EOP
111 2100—NM101—Entity ID Code R 82
2100—NM102—Entity Type R Always indicate a person 1
Qualifier even if a facility
2100—NM103— Name R Servicing provider last name
Last/Org Name
2100—NM104— Name First S Servicing provider first name
2100—NM108— ID Code S National Provider Identifier XX
Qualifier
2100—NM109—ID Code S National Provider Identifier
NM1 Crossover Carrier Name S Not used
NM1 Corrected Priority Payer 2100 S 1 Not used

Name
MIA Medicare Inpatient S Not used

Adjudication
MOA Medicare Outpatient S Not used

Adjudication
REF Other Claim Related S Group Number—Populated 1L

Information for Choice Plus or Options
member
REF Rendering Provider S

Identification
128 2110-REF01-Reference Ident R
Qual
2100-REF02-Reference Ident R
DTM Claim Date Time 2100 S 4

2100-DTM01-Date/Time R Claim statement period date 232
Qualifier qualifier

Use
2100-DTM02-Date R Date (CCYYMMDD)
PER Claim Contact Information 2100 S 1 Not used
AMT Claim Supplemental 2100 S 1 HPHC will indicate claim

Information level interest payments.
This is not part of
balancing. The interest
payments for balancing
will be on the provider’s
PLB record. If no interest
payment for the claim this
segment will not be sent.
135 2100—AMT01—Amount Qual R Interest—if applicable I
Code
2100—AMT02—Monetary R
Amount
QTY Claim Supplemental 2100 S 1 Not used

Quantity Information
SERVICE PAYMENT INFORMATION
SVC Service Information 2110 S 1

139 2100-SVC01-Comp. Med. R
Proced. ID
2110-SVC01-1—Product/ R HC/NU HPHC-supplied
Service ID Qualifier
2110-SVC01-2—Product/ R HPHC adjudicated procedure HPHC-supplied Proc#
Service ID code—the code HPHC is
paying against. Refer to
Companion Guide.
2100-SVC01-3—Procedure S HPHC adjudicated procedure HPHC-supplied
Modifier modifier
2100-SVC01-4—Procedure S HPHC adjudicated procedure HPHC-supplied
Modifier modifier
2110-SVC01-5—Procedure S N/A
Modifier
2110-SVC01-6—Procedure S N/A
Modifier
2110-SVC01-7-Description S N/A
2110-SVC02—Monetary R Submitted/amount charged— HPHC-supplied Charged
Amount may not match submitted
value. Refer to Companion
Guide.
2110-SVC03—Monetary R Amount HPHC paid HPHC-supplied Payment
Amount
2110-SVC04—Product/Service S Submitted revenue code, if
ID applicable. Refer to
Companion Guide.

Use
2110-SVC05—Quantity S Units of service paid HPHC-supplied Days/Cnt
2110-SVC06-1— R HC/NU HPHC-supplied
Product/Service ID Qualifier
2110-SVC06-2— R Submitted procedure code Proc#
Product/Service ID
2100-SVC06-3—Procedure S Submitted procedure
Modifier modifier
Modifier modifier
Modifier modifier
Modifier modifier
2110-SVC06-7-Description S N/A
2100-SVC07-Quantity S Submitted unit of service HPHC-supplied
count if different from
adjudicated
DTM Service Date 2110 S 1 Either single DTM or

multiple DTM segments
will be sent based on
single or multiple dates of
service
146 2110—DTM01—Date/Time R If service line is single date. 472 Service Date
Qual As stored in HPHC
2110—DTM02—Date R Service date (CCYYMMDD)
Or
DTM Service Date 2110 S 1
146 2110—DTM01—Date/Time R Sent if multiple dates of 150 Service Date
Qual service
2110—DTM02—Date R Service start date
CCYYMMDD
2110—DTM01—Date/Time R Sent if multiple dates of 151 Not on paper
Qual service EOP
2110—DTM02—Date R Service end date
(CCYYMMDD)
CAS Service Adjustment 2110 S 99 Service Line Adjustments
148 2110—CAS01—Claim Adj R CO / OA / PI /

Group Code PR / CR
2110—CAS02—Claim Adj R HPHC-supplied
Reason Code
2110—CAS03—Monetary R HPHC-supplied
Amount
2110—CAS04 S N/A
2110—CAS05 S N/A
2110—CAS06 S N/A

Use
2110—CAS07 S N/A
2110—CAS08 S N/A
2110—CAS09 S N/A
2110—CAS10 S N/A
2110—CAS11 S N/A
2110—CAS12 S N/A
2110—CAS13 S N/A
2110—CAS14 S N/A
2110—CAS15 S N/A
2110—CAS16 S N/A
2110—CAS17 S N/A
2110—CAS18 S N/A
2110—CAS19 S N/A
REF Service Identification 2110 S 1

154 2110-REF01-Reference Ident R Sent in case of authorization BB / 6R
Qual number or provider control
number
2100-REF02-Reference Ident R Authorization number or
provider control number
REF Rendering Provider S Not used

Information
AMT Service Supplemental 2110 S 1 Not used

Amount
QTY Service Supplemental 2110 S 1 Not used

Quantity
LQ Health Care Remark Codes 2110 S Not used
PLB Provider Adjustment S 1
165 PLB01—Reference Ident R HPHC provider number

PLB02—Date R December 31 of current year 20YY1231
PLB03—1—Adjustment Reason SR Except ‘FB’
Code
PLB03—2—Reference SS N/A
Identification
PLB04—Monetary Amount R Adjustment Amount
Code

Use
Identification
PLB06—Monetary Amount S Adjustment Amount
Code
Identification
Code
Identification
Code
Identification
Code
Identification
SE Transaction Set Trailer R 1

SE01—Number of Inc Segs R EDI-Assigned
SE02—TS Control Number R EDI-Assigned
GE Functional Group Trailer R 1

GE01—Number Of TS Included R EDI-Assigned
GE02—Group Ctrl Number R EDI-Assigned
IEA Interchange Control Number R 1

IEA01- Number Of Included R EDI-Assigned
Functional Groups
IEA02—Interchange Control R EDI-Assigned
Number

Electronic Remittance Advice 835 Transaction Companion Guide

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Electronic Remittance Advice 835 Transaction Companion Guide

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Electronic Remittance Advice

835 Transaction Companion Guide

Health Care Claim Payment/Advice

Table of Contents ________________________________

Harvard Pilgrim Health Care 2 May 1, 2008

Harvard Pilgrim Health Care 3 May 1, 2008

Establishing Connectivity ________________________

Confidentiality, Privacy and Security

Harvard Pilgrim Health Care 4 May 1, 2008

Harvard Pilgrim Health Care 5 May 1, 2008

MI = Medicare, Medicare Wrap/Miscellaneous Commercial

Harvard Pilgrim Health Care 6 May 1, 2008

REF Loop 1000B—Payee Additional Identification Qualifier TJ–Provider tax ID

Harvard Pilgrim Health Care 7 May 1, 2008

Harvard Pilgrim Health Care 8 May 1, 2008

Choice Plus and Options

Harvard Pilgrim Health Care 9 May 1, 2008

Conditional Data Requirements __________________

Harvard Pilgrim Health Care 10 May 1, 2008

Claim & Service Line Adjustments

Adjustments (Reversals & Corrections)

Mapping Non-Standard Codes

Harvard Pilgrim Health Care 11 May 1, 2008

Harvard Pilgrim Health Care 12 May 1, 2008

Frequently Asked Questions _____________________

Q: If I receive an electronic 835, will I still receive a paper EOP?

Q: When are the 835 files generated?

Q: How many 835 files can I receive?

Harvard Pilgrim Health Care 13 May 1, 2008

Q: Why did I receive a 9999999999 as my NPI in the 835 file?

Q: How do I know if a line has been denied?

Q: How do I calculate the allowed amount?

Q: How do I recognize a claim that has been denied by Harvard Pilgrim?

Harvard Pilgrim Health Care 14 May 1, 2008

Matching Examples ______________________________

Original claim and adjudicated claim have one service line.

Claim# 021230X11234 Total charged: 168.00 Paid: 43.40

Electronic 835 File

Claim header lines CLP* PCT123*1*168*43.4*0*16*021230X11234*22

Detail description SVC*HC:70450*168*43.4**1

Harvard Pilgrim Health Care 15 May 1, 2008

Claim # 021230X11234 Total charged: 327.00 Paid: 72.45

Electronic 835 File

Detail description SVC*HC:88173*327*72.45*0311*3**1

Original claim came in with a service and a count of two.

Claim # 021230X11234 Total charged: 120.00 Paid: 0

Electronic 835 File

Detail description SVC*HC:73520*120*0**1*HC:73510*2

Harvard Pilgrim Health Care 16 May 1, 2008

Original claim has two service lines with standard codes.

Claim# 021230X11234 Total charged: 294.00 Paid: 85.00

Electronic 835 File

The internal procedure code 18 is mapped to revenue code 0450.

Service line 2 SVC*NU:0450*234*0**2**1

Harvard Pilgrim Health Care 17 May 1, 2008

Claim# 021230X11234 Total charged: 3390.22 Paid: 1288.00

Electronic 835 File

Detail description SVC*NU:0762*819*1288**32**13

Service line 2 SVC*NU:0762*155.22*0**32*NU:0250*6

Service line 3 SVC*NU:0762*15*0**32*NU:0301*1

Service line 4 SVC*NU:0762*23*0**32*NU:0305*1

Service line 5 SVC*NU:0762*13*0**32*NU:0305*1

Service line 6 SVC*NU:0762*1106*0**32*NU:0450*1

Claim header lines CLP* PCT123116843.40*16021230X1123422

Detail description SVCHC:70450168*43.4**1

Detail description SVCHC:8817332772.450311*3**1

Detail description SVCHC:73520120*0**1HC:735102

Service line 2 SVCNU:0450234*021

Detail description SVCNU:0762819*12883213

Service line 2 SVCNU:0762155.22*0**32NU:02506

Service line 3 SVCNU:076215*0**32NU:03011

Service line 4 SVCNU:076223*0**32NU:03051

Service line 5 SVCNU:076213*0**32NU:03051

Service line 6 SVCNU:07621106*0**32NU:04501

Service line 7 SVCNU:076262*0**32NU:04601

Service line 8 SVCNU:07621197*03219

Service lline 2 SVCNU:02406.74*0**1*NU:0250

Service line 3 SVCNU:0240156*0**1NU:03002

Service line 4 SVCNU:0240533*0**1NU:03203

Line Descriptions CLP* PCT1231212135.20*HM021230X1123413

Service line 2 SVCHC:8294715120300*1

Service line 3 SVCHC:837354939.20300*1

Service line 4 SVCHC:8452015120300*1

Service line 5 SVCHC:992014300761*1

Service line 6 SVCHC:80051185603001HC:82374

Service line 7 SVCHC:8005117003001HC:82435

Service line 8 SVCHC:8005117003001HC:84132

Service line 9 SVCHC:8005118003001HC:84295

Line Descriptions CLP* PCT12312943330*HM021230X1123413

Service line 1 SVCHC:G00011100300*1

Service line 2 SVCHC:850273800305*1

Service line 3 SVCHC:8561013000305*2

Service line 4 SVCHC:46600283330490*1

Service line 5 SVCNU:051087*0**1

Line Descriptions CLP* PCT12322-294-3330*HM021230X1123413

Service line 1 SVCHC:G0001-1100300*-1

Service line 2 SVCHC:85027-3800305*-1

Service line 3 SVCHC:85610-13000305*-2

Service line 4 SVCHC:46600-28-3330490*-1

Line Descriptions CLPPCT1231294280HM021230X1123413

Service line 1 SVCHC:G00011100300*1

Service line 2 SVCHC:850273800305*1

Service line 3 SVCHC:8561013000305*2

Service line 4 SVCHC:4660028280490*1

Service line 5 SVCNU:051087*0**1