Chapter 1. Purpose and Business Information

id="wpcBookLinkControl_purpose_and_business_information_1" label="Comment on Common Content Head above" book="cc" page="ch01" forumKey="purpose_and_business_information_1" version="15" runat="server"

1.1 Implementation Purpose and Scope

id="wpcBookLinkControl_implementation_purpose_and_scope_1" label="Comment on Common Content Sub Head above" book="cc" page="ch01" forumKey="implementation_purpose_and_scope_1" version="15" runat="server"

For the health care industry to achieve the potential administrative cost savings with Electronic Data Interchange (EDI), standards have been developed to facilitate consistent implementation by all organizations. To facilitate a smooth transition into the EDI environment, uniform implementation is critical.

id="wpcForumControl_wg3_implementation_purpose_and_scope_2" category="Purpose and Business Information" forumKey="wg3_implementation_purpose_and_scope_2" label="Comment on Paragraph above" forumName="Implementation Purpose and Scope: Paragraph 1" runat="server"

The purpose of this implementation guide is to provide standardized data requirements and content for all users of the ASC X12 Health Care Claim Payment/ Advice (835). The 835 also may contain information about future remittances that are to be paid when specified services are completed. This implementation guide provides a detailed explanation of the transaction set by defining data content, identifying valid code tables, and specifying values that are applicable for electronic claims payment. The intention of the developers of the 835 is represented in this guide.

id="wpcForumControl_wg3_implementation_purpose_and_scope_3" category="Purpose and Business Information" forumKey="wg3_implementation_purpose_and_scope_3" label="Comment on Paragraph above" forumName="Implementation Purpose and Scope: Paragraph 2" runat="server"

This implementation guide is designed to assist those who send and/or receive Electronic Remittance Advice (ERA) and/or payments in the 835 format.

id="wpcForumControl_wg3_implementation_purpose_and_scope_4" category="Purpose and Business Information" forumKey="wg3_implementation_purpose_and_scope_4" label="Comment on Paragraph above" forumName="Implementation Purpose and Scope: Paragraph 3" runat="server"

Entities receiving the 835 include, but are not limited to, hospitals, nursing homes, laboratories, physicians, dentists, and allied professional groups. All of these entities are referred to as payees or providers within this document.

id="wpcForumControl_wg3_implementation_purpose_and_scope_5" category="Purpose and Business Information" forumKey="wg3_implementation_purpose_and_scope_5" label="Comment on Paragraph above" forumName="Implementation Purpose and Scope: Paragraph 4" runat="server"

Organizations sending the 835 include insurance companies, Third Party Administrators (TPAs), service corporations, state and federal agencies and their contractors, plan purchasers, and any other entities that process health care reimbursements. Other business partners affiliated with the 835 include Depository Financial Institutions (DFIs), billing services, consulting services, vendors of systems, software and EDI translators, EDI network intermediaries such as Automated Clearing Houses, value-added networks, and telecommunication services.

id="wpcForumControl_wg3_implementation_purpose_and_scope_6" category="Purpose and Business Information" forumKey="wg3_implementation_purpose_and_scope_6" label="Comment on Paragraph above" forumName="Implementation Purpose and Scope: Paragraph 5" runat="server"

All of these entities are referred to as payers or health plans within this document.

id="wpcForumControl_wg3_implementation_purpose_and_scope_7" category="Purpose and Business Information" forumKey="wg3_implementation_purpose_and_scope_7" label="Comment on Paragraph above" forumName="Implementation Purpose and Scope: Paragraph 6" runat="server"

id="wpcForumControl_x322_pabi_99" category="Purpose and Business Information" forumKey="x322_pabi_99" label="Add New Section" forumName="Implementation Purpose and Scope: Section Addition" runat="server"