Understanding 835 remittances

An 835 is the standard electronic form of the payer’s itemized payment explanation. A remittance contains claims. Each claim contains service lines. Claims and service lines can both have adjustments. The adjustments account for the full difference between the charged amount and the paid amount. Lemma provides the same remittance as a raw X12 file or as JSON. This page describes the content of both formats.

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Claims

The amount billed to a payer for one patient’s care is known as a claim. A claim covers the services that a healthcare practitioner delivered during one or more encounters. A practitioner is not always a physician. The same claim and remittance process applies to dentists, nurse practitioners, optometrists and more. The total that a practice bills on a claim is known as the charged amount. It is a list price. Contracted payers almost always pay less than this amount, and the contract between the practice and the payer sets the difference. The charged amount is not the revenue that the practice will receive.

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Service lines

A service line is one procedure within a claim. A service line identifies the procedure with a standardized procedure code. The line also gives the modifiers for that code, the number of units, the location of the service, and the practitioner who performed it. The line has its own charged, allowed, and paid amounts. The allowed amount is the contracted price for that procedure under the agreement between the practice and that payer. The payer calculates the payment from the allowed amount, not from the charged amount. Allowed amounts belong to lines, so the claim’s allowed total is the sum of its lines.

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Adjustments

An adjustment explains one part of the difference between the charged amount and the paid amount. Adjustments account for that full difference on every claim. An adjustment has three parts: a group, a reason, and an amount. The group identifies who is responsible for the amount. The reason identifies why the payer made the adjustment.

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Adjustment signs and levels

Adjustment amounts are signed. A positive amount reduces the payment, and a negative amount increases it. Negative amounts are valid and they occur often. For example, a secondary payer can allow more than the amount that the practice submitted to it. The secondary payer reports the difference as a negative adjustment. A payer reports each adjustment at the claim level or at the line level. The payer does not report the same adjustment at both levels.

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Provider-level adjustments

A provider-level adjustment is not part of any claim. It is an amount that the payer adds to or subtracts from the payment, unrelated to any claim on that remittance. The provider-level adjustments usually relate to claims previously paid, some examples:

• A payer can recover an amount that it overpaid on an earlier claim.
• A payer can report interest that it owes because it paid late.
• A payer can forward a balance to a future remittance.

A provider-level adjustment is signed in the same way as a claim adjustment, so a positive amount reduces the payment. A provider-level adjustment can equal the full amount of the payment. In that case the remittance reports a total payment of zero, and the payer carries the remaining balance forward to a later remittance.