Glossary

The terms these pages use, in plain language. For a walk through a real file, read The 835 in five minutes.

The file and its parts

Interchange

The outer envelope of a file, from ISA to IEA. It names the sender and the receiver, the date and time, and carries a control number. It holds one or more functional groups. oxedi.write produces one interchange.

Functional group

A group of transactions inside an interchange, from GS to GE. GS08 names the version of the format, such as 005010X221A1.

Transaction set

One 835, from ST to SE. Also called a transaction. In an 835 it is one payment, so it is one row of payments. oxedi.stream yields one batch per transaction.

Segment

One record of the file: an id such as CLP, then its elements, then the segment terminator (~ by default). Every byte of a file belongs to exactly one segment, which is how oxedi writes a file back unchanged.

Element

One value inside a segment. Elements are separated by the element separator (* by default) and numbered from 1, so CLP02 is the second element of CLP.

Component

One part of a composite element. Components are separated by the component separator (: by default). SVC01-2 is the second component of the first element of SVC, as in SVC*HC:99213.

Delimiters

The characters that split a file: element separator, component separator, segment terminator, and the optional repetition separator and release character. A file declares them in its ISA segment, and oxedi reads them from there.

Qualifier

An element that says what the next value means. N1*PR is the payer and N1*PE the payee. DTM*232 is a statement start date. The docs write a segment with its qualifier this way.

Loop

A group of segments that repeats together, named by the implementation guide: 1000A (the payer), 1000B (the payee), 2000 (a group of claims), 2100 (a claim), 2110 (a service line). A diagnostic's path names the open loops, with the instance number: 2100#2 is the second claim.

Implementation guide

The published rules for using the 835 in health care: which segments, loops, elements and codes a file has. The 5010 guide is 005010X221A1 and the 4010 guide 004010X091A1.

Spec

oxedi's description of the format, in JSON: loops, segments, elements, code lists, balancing rules and the tables to fill. oxedi ships a 5010 and a 4010 spec, and you can patch them. See Customizing the spec.

Control number

A number that must match between a header and its trailer: ISA13 and IEA02, GS06 and GE02, ST02 and SE02. The trailers also carry counts (SE01, GE01, IEA01), so a receiver can check that nothing is missing.

5010 and 4010

The two versions of the 835 that oxedi reads and writes. 5010 is the default. A file declares its version in ISA12 and GS08.

Payments and claims

ERA

Electronic remittance advice: another name for the 835.

Payer

Who pays: usually a health plan. It sends the 835. Its loop is 1000A, opened by N1*PR.

Payee

Who is paid: usually the provider that sent the claims. It receives the 835. Its loop is 1000B, opened by N1*PE.

Check and EFT

The two usual ways the money moves: a paper check, or an electronic funds transfer (EFT). The money travels apart from the 835. BPR04 holds the payment method as a code, such as CHK or ACH.

Trace number

TRN02, the check or EFT trace number. It lets the payee match the 835 to the money it received. It is the trace_number column of payments.

Claim

A request for payment the provider sent for some care. In the 835, each claim is a CLP segment and its loop 2100, and one row of claims.

Claim status

CLP02, a code for how the payer processed the claim. The 5010 spec lists ten codes. The Polars recipe counts status 4 as a denial.

Service line

One billed procedure or service of a claim: an SVC segment and its loop 2110, and one row of services.

Adjustment

A reason the paid amount differs from the billed one, with its amount: a CAS segment on a claim or on a service line. Each reason in a CAS is one row of adjustments.

Group code

CAS01, who bears an adjustment: CO contractual obligation, PR patient responsibility, OA other adjustment, PI payer-initiated reduction, and CR correction in 4010 files.

CARC

Claim adjustment reason code: the reason of an adjustment, in CAS02, CAS05 and so on. It is the reason_code column of adjustments. The codes come from an external code list whose texts are licensed, so these pages do not reproduce them. Look a code up in the official list.

RARC

Remittance advice remark code: a remark that adds detail to an adjustment, also from an external, licensed code list. In the 835 they sit in LQ (on a service line) and in MIA and MOA (on a claim). The built-in tables have no column for them. The segments stay in the document, and a spec patch can add a column.

Provider adjustment

An amount added to or taken from the whole payment, not from one claim: a PLB segment. Each adjustment in a PLB is one row of provider_adjustments.

Balancing

The amounts of an 835 must add up. A service line's charge minus its payment equals its adjustments. A claim's charge minus its payment equals its adjustments and those of its service lines. BPR02 equals the claims' payments minus the provider adjustments. A rule that fails is a level 3 diagnostic.

Reading and validating

Diagnostic

One finding about the data of a file: the rule that failed, where, and the value. oxedi returns diagnostics as data instead of raising. See Diagnostics.

SNIP level

The level a validation rule belongs to. oxedi reports three:

• Level 1, integrity: envelopes, control numbers and counts, segment structure.
• Level 2, requirements: required elements, types, lengths, codes and the loop structure.
• Level 3, balancing: amounts that must add up.

Document

The file as oxedi holds it, indexed into segments and kept byte for byte. result.document.write() returns the file unchanged.

Envelope

What the writer needs besides the tables: sender, receiver, date, time and control number. In Python it is oxedi.Envelope. See Writing.

Lossless

Nothing in the file is dropped or changed. Unknown segments stay in the document, and a file writes back exactly as it was read.

Segment ids

Id	Name	What it holds in an 835
ISA	Interchange control header	Sender, receiver, date, time, version, control number and the delimiters.
IEA	Interchange control trailer	The number of groups and the interchange control number.
GS	Functional group header	Application sender and receiver, date, time, control number, version.
GE	Functional group trailer	The number of transactions and the group control number.
ST	Transaction set header	Starts one 835 and its control number.
SE	Transaction set trailer	The number of segments and the transaction control number.
BPR	Financial information	The total paid, credit or debit, method, format and date.
TRN	Reassociation trace number	The trace number and the payer identifier.
REF	Reference identification	An id, with a qualifier that says which one.
DTM	Date or time reference	A date, with a qualifier that says which one.
N1	Party identification	The payer (N1*PR) or the payee (N1*PE): name and id.
N3	Address	A street address.
N4	City, state and ZIP code	City, state and postal code.
PER	Contact information	A contact name and number.
LX	Header number	Starts a group of claims (loop 2000).
CLP	Claim payment information	A claim: id, status, charge, payment, patient responsibility.
NM1	Individual or organization name	A person or organization of the claim, such as the patient (NM1*QC).
MIA, MOA	Inpatient and outpatient adjudication information	Adjudication amounts and remark codes of a claim.
AMT	Supplemental amount	An amount, with a qualifier that says which one.
SVC	Service payment information	A service line: procedure, charge, payment, units.
CAS	Claim or service adjustment	Up to six adjustments of one group: reason, amount, quantity.
LQ	Health care remark codes	Remark codes of a service line.
PLB	Provider adjustment	Up to six adjustments of the whole payment.