This blog post describes the mapping specifications and the conversion between a HIPAA 835 electronic remittance advice and a report form in PDF format.
This conversion is different from HIPAA 837 conversions because there is no corresponding standard form, such as CMS 1500 or UB04 that can be used in the mapping process. Instead, we followed the instructions from Medicare National Standard Intermediary Remittance Advice and developed a generic report form for remittance advice in PDF format, as shown below. This mapping is not meant to be final since users may want to customize the layout of the form. Regardless, this mapping specification can be served as a template for future customization. You can test the map by going to Redix HIPAA Compliance and Conversion Demo.
Mapping Specification
Below is a table to describe the mapping between HIPAA 835 and the above report file.
| HIPAA 835 Electronic Remittance Advice | CMS Report |
|---|---|
| FPE | 2000 TS303, converted |
| PAID | BPR16, converted |
| CLM# | calc: physical count of claims per ST (not reset outside of ST) |
| TOB | 2100 CLP08 + 09 |
| Patient | 2100 NM103-05 (NM101="QC") |
| HIC | 2100 NM109 |
| PAT STAT | "01" |
| CLAIM STAT | "1" |
| SVC FROM | 2100 DTP03 (DTP01="232"), converted |
| SVC THRU | 2100 DTP03 (DTP01="233"), converted |
| PCN | 2100 CLP01 |
| MRN | Not Mapped |
| ICN | 2100 CLP07 |
| CHARGES | Not Mapped |
| REPORTED | 2100 CLP03 |
| NCVD/DENIED | "0.00" |
| CLAIM ADS | "0.00" |
| COVERED | 2100 AMT02 (AMT01="AU") |
| DAYS/VISITS | Not Mapped |
| COST REPT | "0" |
| COVD/UTIL | "0" |
| NON-COVERED | "0" |
| COVD VISITS | "0" |
| NCOVVISITS | "0" |
| PAYMENT DATA | Not Mapped |
| DRG AMOUNT | "0.00" |
| DRG/OPER/CAP | "0.00" |
| LINE ADJ AMT | "0.00" |
| OUTLIER | "0.00" |
| CAP OUTLIER | "0.00" |
| CASH DEDUCT | CAS03 (CAS01="PR", CAS02="1") |
| BLOOD DEDUCT | CAS03 (CAS01="PR", CAS02="66") |
| COINSURANCE | CAS03 (CAS01="PR", CAS02="2") |
| PAT REFUND | "0.00" |
| MSP LIAB MET | "0.00" |
| REIM RATE | 2100 MOA01 |
| MSP PRIM PAYER | "0.00" |
| PROF COMPONENT | "0.00" |
| ESRD AMOUNT | CAS03 (CAS01="CO", CAS02="118") |
| PROC CD AMOUNT | 2100 MOA02 |
| ALLOWED/REIM | 2100 CLP04 |
| G/R AMOUNT | CAS03 (CAS01="CO", CAS02="43") |
| INTERST | 2100 AMT02 (AMT01="I") |
| CONTRACT | CAS03 (CAS01="CO", CAS02="A2") |
| PER DIM AMT | 2100 MOA01 |
| NET REIM AMT | 2100 CLP04 |
| REV | 2110 SVC04 |
| DATE | |
| HCPCS | 2110 SVC01:02 |
| APC/HIPPS | |
| MODS | 2110 SVC01:03 |
| QTY | 2110 SVC05 |
| CHARGES | 2110 SVC02 |
| ALLOW/REIM | 2110 SVC03 |
| GC | 2110 CAS01 |
| RSN | 2110 CAS02 |
| AMOUNT | 2110 CAS03 |
| REMARK CODES | 2110 LQ02 (LQ01="HE"), Last occurrence |
| NOTES | "REMARK CODES" code value is obtained from database "835Data" |
| REASON CODES | 2110 CAS01 (unique only) |
| DESCRIPTION | "REMARK CODES" code value is obtained from the database "835Data" |
Some of the notes about this conversion:
- Only if the input file 835 is validated successfully, the file will be converted.
- Each remittance advice will be generated in a separate PDF file.
Example
Below is an 835 example:
ISA*00* *00* *ZZ*123456789012345*ZZ*123456789012345*030101*1253*^*00501*987654321*1*T*: GS*HP*123456789012345*123456789012345*19991231*0802*123456789*X*005010X221A1 ST*835*1234 BPR*C*150000*C*ACH*CTX*01*999999992*DA*123456*1512345678*123121234*01*999988880*DA*98765*20020913 TRN*1*12345*1512345678 DTM*405*20020916 N1*PR*INSURANCE COMPANY OF TIMBUCKTU N3*1 MAIN STREET N4*TIMBUCKTU*AK*89111 REF*2U*999 PER*BL*JOHN WAYNE*TE*8005551212*EX*123 N1*PE*REGIONAL HOPE HOSPITAL*XX*6543210903 N4*SEGMENT MISSING FROM IG*AK*89111 LX*110212 TS3*6543210903*11*20021231*1*211366.97********138018.4**73348.57 TS2*2178.45*1919.71**56.82*197.69*4.23 CLP*666123*1*211366.97*138018.4**MA*1999999444444*11*1 CAS*CO*45*73348.57 NM1*QC*1*JONES*SAM*O***HN*666666666A MIA*0***138018.4 DTM*232*20020816 DTM*233*20020824 QTY*CA*8 LX*130212 TS3*6543210909*13*19961231*1*15000********11980.33**3019.67 CLP*777777*1*15000*11980.33**MB*1999999444445*13*1 CAS*CO*45*3019.67 NM1*QC*1*BORDER*LIZ*E***HN*996669999B MOA***MA02 DTM*232*20020512 PLB*6543210903*20021231*CV:CP*-1.27 SE*30*1234 GE*1*123456789 IEA*1*987654321
About Us
Redix International, Inc. is an enterprise software company. Redix develops software and provides services to help organizations convert their proprietary or organization-specific data to standardized data. Among the standardized formats supported are X12, EDIFACT, XML, NSF, UB92, HIPAA, HL7, CDA, Blue-Ribbon, FHIR, NCPDP, and PDF.
