We are receiving 835 data from a payer that only contains Table 1 information. The payment amount is $0, so the file is not being used to move money. The file contains the required segments from Table 1, and the closing SE, GS, and IEA, but does not contain any claim data (Table 2) nor any PLB information (Table 3). There is no information in the file for the provider to act upon, so there is no reason to send the file. I do not see anything in the front matter that prohibits this. Is this file compliant?
Payer is providing an 835 file with Table 1 information only. BPR01 = H, BPR02 = 0, BPR04=NON. TRN02 has a value (not sure what it is). 1000A and 1000B loops are populated correctly, then the file ends with the SE, GE, and IEA. No claim data (Table 2) or PLB information (Table 3) is included.
Section 1.4 Business Usage of the X12N 005010x221 835 TR3 states
“The 835 is intended to meet the particular needs of the health care industry for the
payment of claims and transfer of remittance information. The 835 can be used to make
a payment, send an Explanation of Benefits (EOB) remittance advice, or make a payment
and send an EOB remittance advice from a payer to a payee, either directly or through
a DFI.”
Section 1.10.1.1 Payment states
“The 835 contains information about the payee, the payer, the amount, and any identifying
information of the payment.”
And section 1.10.1.4 Remittance states
“As a remittance advice, the 835 provides detailed payment information relative to the
health care claim(s) and, if applicable, describes why the total original charges have not
been paid in full. This remittance information is provided as documentation for the
payment, as well as input to the payee's patient accounting system/accounts receivable
(A/R) and general ledger applications.”
Section 1.10.2 Data Use by Business Use states
“Although the remittance information in Tables 2 and 3 are not always provided, the
intention of this business use of the 835 is for payers to provide some claim or
provider-specific information along with the payment information.
When dollars and data are delivered separately, an 835 with no Table 2 or PLB segment
in Table 3 can initiate a financial transaction.
NOTE
The 835 is used to transmit payment and data needed for the posting by a provider
subsequent to the adjudication of a claim. Non-adjudicated claim information should be
carried in the ASC X12 Health Care Claim Status Notification Transaction Set (277).”
While the usage information for Table 2 and Table 3 indicate that neither are required to be present, the front matter information referenced above show the intent that the 835 transaction should include payment and remittance information needed by the provider for posting, and that payment information, along with claim or provider-specific information, be included in the transaction. The example provided does not include any payment information (BPR02=0), and since both Table 2 and Table 3 are omitted there is no claim or provider-specific information, so this example does not conform to the intent of the TR3.
Related RFIs: 1870, 1581, 2228