EDI 835

Healthcare Claim Payment / Advice

The EDI 835 transaction, also known as the Healthcare Claim Payment/Advice, is a standardized electronic payment and remittance advice format regulated by HIPAA (Health Insurance Portability and Accountability Act).

Speak to an EDI expert
EDI transactions header

What is an EDI 835?

The EDI 835 (Healthcare Claim Payment/Advice) is an electronic transaction used primarily in the healthcare industry to facilitate payments and remittance advice between health insurance providers (or payers) and healthcare providers (such as doctors, hospitals, or clinics).

It is part of the HIPAA (Health Insurance Portability and Accountability Act) standard for healthcare transactions and helps streamline the payment and claims process.
 

Purpose of an EDI 835:
 

  • Claims Payment: It notifies healthcare providers about payments for services rendered to patients. The payment details, including the amount, are provided in the EDI 835.
     
  • Remittance Advice: The EDI 835 serves as a remittance advice, explaining how the payment was calculated, including adjustments, denials, or reductions.
     
  • Explanation of Benefits (EOB): It functions similarly to an EOB, helping providers understand how much was paid, what was adjusted, and what the patient may owe.

How These Work Together in a Typical Enrollment Process:

  • Employer or provider sends an EDI 270 to check eligibility.
  • Insurance provider responds with an EDI 271 confirming eligibility.
  • Employer submits an EDI 834 to enroll or update coverage for employees.
  • Insurance company sends an EDI 997 or EDI 999 to acknowledge the receipt of EDI 834.
  • Employer sends an EDI 820 to pay premiums for enrolled members.
  • If a claim is submitted, an EDI 276 is sent, and the insurance provider responds with EDI 277.
  • Insurance provider sends an EDI 835 to show claim payment details.

Key Components of an EDI 835:

  • Payment Amount: The total payment being made to the provider for specific claims.
  • Adjustments: Details about reductions or adjustments to the payment, such as co-pays, deductibles, or non-covered services.
  • Claim Status: Information about whether claims are approved, denied, or pending further review.
  • Patient Responsibility: Any amounts that the patient needs to pay out-of-pocket, such as co-pays or deductibles.

Other Common X12 Transactions Related to EDI 835

View the most commonly used EDI transactions.

More EDI Transactions
EDI 270 transaction healthcare provider

Cleo can assist with EDI 835s (and so much more)

Choose the EDI Integration package that best fits your business:

 

  • Create and deploy your own integrations using Cleo's intuitive, self-service design platform.
  • Utilize Cleo's EDI-managed services team to design and build your integrations.
  • Blend our EDI expertise and your business knowledge together in any manner that suits your use case.

New to EDI? Learn more

What is Electronic Data Interchange? Cloud-EDI EDI Integration EDI Transaction Codes Top EDI Providers for 2025 EDI for Logistics EDI for Suppliers What is an EDI System? EDI Managed Services EDI vs. API

Keep a list of all X12 EDI transaction sets at hand.

Access a free EDI Transaction Set Guide

Access EDI Transactions Guide