EDI 835 Data Transformation Documentation

EDI 835 Data Transformation

Transform and create EDI messages using one of our two supported JSON formats.

Our current supported EDI version: 005010

Need help with some of our documentation? Feel free to contact our support team, and one of our support team members will be happy to assist you.

EDI 835 Request to Smart JSON Response

Transforms the EDI 835 message into our Smart JSON format. Recommended unless you need specific requirements that the Smart JSON may not support.

post https://api-edi.splinxtechnologies.com/v1/edi-transformation/edi835-to-smart

Request headers

Authentication

To make REST API calls, make sure to include your account's email and password in a Base64 encrypted format in the Basic authentication scheme. The value is <Account-Email> and <Account-Password>

LicenseId

Response fields

Field

Description

FinancialTransactionAction

string

PaymentAmount

string

IsCredit

boolean

IsDebit

boolean

PaymentMethod

string

PaymentFormat

string

SenderDepositoryFinancialInstitutionNumber

string

SenderBankAccountNumber

string

PayerIdentifier

string

ReceiverOrProviderBankIdNumber

string

ReceiverOrProviderAccountNumber

string

EffectiveDate

string

FinancialTransactionTraceNumber

string

FinancialTransactionPayerIdentifier

string

ProductionDate

string

Payer

Payer represents the payer of the transaction. Use class Payer for reference.

Payee

Payee represents the payee of the transaction. Use class Payee for reference.

ClaimPaymentDetails

List<ClaimPaymentDetails> represents the details for the claim payment. Use class ClaimPaymentDetails for reference.

ProviderAdjustments

List<ProviderAdjustment> represents the provider adjustments for the transaction. Use class ProviderAdjustment for reference.

Sample request

EDI 835 Copy

ISA*00*          *00*          *ZZ*SUBMITTERS ID  *ZZ*RECEIVERS ID   *220412*1253*^*00501*000000001*0*P*:~GS*XX*SENDER CODE*RECEIVERCODE*20220412*1513*1*X*005010X221A1~ST*835*1234~BPR*C*150000*C*ACH*CTX*01*999999992*DA*123456*1512345678**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~N1*PE*REGIONAL HOPE HOSPITAL*XX*6543210903~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*28*1234~GE*1*1~IEA*1*000000001~

Sample response

Smart JSON Copy

{
  "FinancialTransactionAction": "Payment Accompanies Remittance Advice",
  "PaymentAmount": "150000",
  "IsCredit": true,
  "PaymentMethod": "Automated Clearing House (ACH)",
  "PaymentFormat": "Corporate Trade Exchange (CTX) (ACH)",
  "SenderDepositoryFinancialInstitutionNumber": "999999992",
  "SenderBankAccountNumber": "123456",
  "PayerIdentifier": "1512345678",
  "ReceiverOrProviderBankIdNumber": "999988880",
  "ReceiverOrProviderAccountNumber": "98765",
  "EffectiveDate": "09/13/2002",
  "FinancialTransactionTraceNumber": "12345",
  "FinancialTransactionPayerIdentifier": "1512345678",
  "ProductionDate": "09/16/2002",
  "Payer": {
    "Name": "INSURANCE COMPANY OF TIMBUCKTU",
    "AddressInformation": {
      "StreetAddress1": "1 MAIN STREET",
      "City": "TIMBUCKTU",
      "State": "AK",
      "ZipCode": "89111"
    },
    "AdditionalIdentifiers": [
      {
        "Identifier": "999",
        "IdentifierType": "Payer Identification Number"
      }
    ]
  },
  "Payee": {
    "Name": "REGIONAL HOPE HOSPITAL"
  },
  "ClaimPaymentDetails": [
    {
      "ProviderSummaryInfomation": {
        "ProviderIdentification": "6543210903",
        "FiscalPeriodDate": "12/31/2002",
        "TotalClaimsCharges": "211366.97"
      },
      "ClaimPaymentInformation": [
        {
          "PatientControlNumber": "666123",
          "ClaimStatus": "Processed as Primary",
          "ClaimChargeAmount": "211366.97",
          "ClaimPaymentAmount": "138018.4",
          "PayerClaimControlNumber": "1999999444444",
          "FacilityCode": "11",
          "ClaimFrequencyCode": "Admit thru discharge claim",
          "ClaimAdjustments": [
            {
              "AdjustmentCategory": "Contractual Obligations",
              "ClaimAdjustmentDetails": [
                {
                  "AdjustmentAmount": "73348.57",
                  "AdjustmentReason": "Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement"
                }
              ]
            }
          ],
          "PatientName": {
            "FirstName": "SAM",
            "LastNameOrOrganizationName": "JONES",
            "MiddleName": "O",
            "Identifier": "666666666A",
            "IdentifierType": "Health Insurance Claim (HIC) Number"
          },
          "InpatientAdjudicationInformation": {
            "CoveredDaysOrVisitCount": "0",
            "ClaimDiagnosisRelatedGroupAmount": "138018.4"
          },
          "ClaimDates": [
            {
              "Date": "08/16/2002",
              "Qualifier": "Claim Statement Period Start"
            },
            {
              "Date": "08/24/2002",
              "Qualifier": "Claim Statement Period End"
            }
          ],
          "ClaimSupplementalInformationQuantity": [
            {
              "Value": "8",
              "CodeQualifier": "Covered - Actual"
            }
          ]
        }
      ]
    },
    {
      "ProviderSummaryInfomation": {
        "ProviderIdentification": "6543210909",
        "FiscalPeriodDate": "12/31/1996",
        "TotalClaimsCharges": "15000"
      },
      "ClaimPaymentInformation": [
        {
          "PatientControlNumber": "777777",
          "ClaimStatus": "Processed as Primary",
          "ClaimChargeAmount": "15000",
          "ClaimPaymentAmount": "11980.33",
          "PayerClaimControlNumber": "1999999444445",
          "FacilityCode": "13",
          "ClaimFrequencyCode": "Admit thru discharge claim",
          "ClaimAdjustments": [
            {
              "AdjustmentCategory": "Contractual Obligations",
              "ClaimAdjustmentDetails": [
                {
                  "AdjustmentAmount": "3019.67",
                  "AdjustmentReason": "Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement"
                }
              ]
            }
          ],
          "PatientName": {
            "FirstName": "LIZ",
            "LastNameOrOrganizationName": "BORDER",
            "MiddleName": "E",
            "Identifier": "996669999B",
            "IdentifierType": "Health Insurance Claim (HIC) Number"
          },
          "OutpatientAdjudicationInformation": {
            "ClaimPaymentRemarkCodes": [
              "If you do not agree with this determination, you have the right to appeal. You must file a written request for an appeal within 180 days of the date you receive this notice"
            ]
          },
          "ClaimDates": [
            {
              "Date": "05/12/2002",
              "Qualifier": "Claim Statement Period Start"
            }
          ]
        }
      ]
    }
  ],
  "ProviderAdjustments": [
    {
      "ProviderIdentifier": "6543210903",
      "FiscalPeriodDate": "12/31/2002",
      "Adjustments": [
        {
          "ReferenceIdentification": "CP",
          "AdjustmentAmount": "-1.27",
          "AdjustmentReason": "Capital Passthru"
        }
      ]
    }
  ]
}

EDI 835 Request to JSON Response

Transforms an EDI 835 message into JSON.

post https://api-edi.splinxtechnologies.com/v1/edi-transformation/edi835-to-json

Request headers

Authentication

To make REST API calls, make sure to include your account's email and password in a Base64 encrypted format in the Basic authentication scheme. The value is <Account-Email> and <Account-Password>

LicenseId

Sample request

EDI 835 Copy

ISA*00*          *00*          *ZZ*SUBMITTERS ID  *ZZ*RECEIVERS ID   *220412*1253*^*00501*000000001*0*P*:~GS*XX*SENDER CODE*RECEIVERCODE*20220412*1513*1*X*005010X221A1~ST*835*1234~BPR*C*150000*C*ACH*CTX*01*999999992*DA*123456*1512345678**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~N1*PE*REGIONAL HOPE HOSPITAL*XX*6543210903~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*28*1234~GE*1*1~IEA*1*000000001~

Sample response

JSON Copy

{
  "InterchangeControlHeaderSegment": {
    "ISA_01_AuthorizationInformationQualifier_ID": "00",
    "ISA_02_AuthorizationInformation_AN": "          ",
    "ISA_03_SecurityInformationQualifier_ID": "00",
    "ISA_04_SecurityInformation_AN": "          ",
    "ISA_05_InterchangeIDQualifier_ID": "ZZ",
    "ISA_06_InterchangeSenderID_AN": "SUBMITTERS ID  ",
    "ISA_07_InterchangeIDQualifier_ID": "ZZ",
    "ISA_08_InterchangeReceiverID_AN": "RECEIVERS ID   ",
    "ISA_09_InterchangeDate_DT": "220412",
    "ISA_10_InterchangeTime_TM": "1253",
    "ISA_11_RepetitionSeparator": "^",
    "ISA_12_InterchangeControlVersionNumber_ID": "00501",
    "ISA_13_InterchangeControlNumber_N": "000000001",
    "ISA_14_AcknowledgmentRequest_ID": "0",
    "ISA_15_InterchangeUsageIndicator_ID": "P",
    "ISA_16_ComponentElementSeparator": ":"
  },
  "FunctionalGroups": [
    {
      "FunctionalGroupHeaderSegment": {
        "GS_01_FunctionalIdentifierCode_ID": "XX",
        "GS_02_ApplicationSendersCode_AN": "SENDER CODE",
        "GS_03_ApplicationReceiversCode_AN": "RECEIVERCODE",
        "GS_04_Date_DT": "20220412",
        "GS_05_Time_TM": "1513",
        "GS_06_GroupControlNumber_N": "1",
        "GS_07_ResponsibleAgencyCode_ID": "X",
        "GS_08_VersionReleaseIndustryIdentifierCode_AN": "005010X221A1"
      },
      "TransactionSets": [
        {
          "TransactionSetHeader": {
            "ST_01_TransactionSetIdentifierCode_ID": "835",
            "ST_02_TransactionSetControlNumber_AN": "1234",
            "ST_03_ImplementationConventionReference_AN": null
          },
          "FinancialInformation": {
            "BPR_01_TransactionHandlingCode_ID": "C",
            "BPR_02_MonetaryAmount_R": "150000",
            "BPR_03_CreditDebitFlagCode_ID": "C",
            "BPR_04_PaymentMethodCode_ID": "ACH",
            "BPR_05_PaymentFormatCode_ID": "CTX",
            "BPR_06_DfiIdNumberQualifier_ID": "01",
            "BPR_07_DfiIdentificationNumber_AN": "999999992",
            "BPR_08_AccountNumberQualifier_ID": "DA",
            "BPR_09_AccountNumber_AN": "123456",
            "BPR_10_OriginatingCompanyIdentifier_AN": "1512345678",
            "BPR_11_OriginatingCompanySupplementalCode_AN": null,
            "BPR_12_DfiIdNumberQualifier_ID": "01",
            "BPR_13_DfiIdentificationNumber_AN": "999988880",
            "BPR_14_AccountNumberQualifier_ID": "DA",
            "BPR_15_AccountNumber_AN": "98765",
            "BPR_16_Date_DT": "20020913",
            "BPR_17_BusinessFunctionCode_ID": null,
            "BPR_18_DfiIdNumberQualifier_ID": null,
            "BPR_19_DfiIdentificationNumber_AN": null,
            "BPR_20_AccountNumberQualifier_ID": null,
            "BPR_21_AccountNumber_AN": null
          },
          "ReassociationTraceNumber": {
            "TRN_01_TraceTypeCode_ID": "1",
            "TRN_02_ReferenceIdentification_AN": "12345",
            "TRN_03_OriginatingCompanyIdentifier_AN": "1512345678",
            "TRN_04_ReferenceIdentification_AN": null
          },
          "ForeignCurrencyInformation": null,
          "ReceiverIdentification": null,
          "VersionIdentification": null,
          "ProductionDate": {
            "DTM_01_DateTimeQualifier_ID": "405",
            "DTM_02_Date_DT": "20020916",
            "DTM_03_Time_TM": null,
            "DTM_04_TimeCode_ID": null,
            "DTM_05_DateTimePeriodFormatQualifier_ID": null,
            "DTM_06_DateTimePeriod_AN": null
          },
          "PayerIdentification_Loop_1000A": {
            "PayerIdentification": {
              "N1_01_EntityIdentifierCode_ID": "PR",
              "N1_02_Name_AN": "INSURANCE COMPANY OF TIMBUCKTU",
              "N1_03_IdentificationCodeQualifier_ID": null,
              "N1_04_IdentificationCode_AN": null,
              "N1_05_EntityRelationshipCode_ID": null,
              "N1_06_EntityIdentifierCode_ID": null
            },
            "PayerAddress": {
              "N3_01_AddressInformation_AN": "1 MAIN STREET",
              "N3_02_AddressInformation_AN": null
            },
            "PayerCityStateZipCode": {
              "N4_01_CityName_AN": "TIMBUCKTU",
              "N4_02_StateOrProvinceCode_ID": "AK",
              "N4_03_PostalCode_ID": "89111",
              "N4_04_CountryCode_ID": null,
              "N4_05_LocationQualifier_ID": null,
              "N4_06_LocationIdentifier_AN": null,
              "N4_07_CountrySubdivisionCode_ID": null
            },
            "AdditionalPayerIdentification": [
              {
                "REF_01_ReferenceIdentificationQualifier_ID": "2U",
                "REF_02_ReferenceIdentification_AN": "999",
                "REF_03_Description_AN": null,
                "REF_04_ReferenceIdentifier": null
              }
            ],
            "PayerBusinessContactInformation": null,
            "PayerTechnicalContactInformation": null,
            "PayerWebSite": null
          },
          "PayeeIdentification_Loop_1000B": {
            "PayeeIdentification": {
              "N1_01_EntityIdentifierCode_ID": "PE",
              "N1_02_Name_AN": "REGIONAL HOPE HOSPITAL",
              "N1_03_IdentificationCodeQualifier_ID": "XX",
              "N1_04_IdentificationCode_AN": "6543210903",
              "N1_05_EntityRelationshipCode_ID": null,
              "N1_06_EntityIdentifierCode_ID": null
            },
            "PayeeAddress": null,
            "PayeeCityStateZipCode": null,
            "PayeeAdditionalIdentification": null,
            "RemittanceDeliveryMethod": null
          },
          "HeaderNumber_Loop_2000": [
            {
              "HeaderNumber": {
                "LX_01_AssignedNumber_N": "110212"
              },
              "ProviderSummaryInformation": {
                "TS3_01_ReferenceIdentification_AN": "6543210903",
                "TS3_02_FacilityCodeValue_AN": "11",
                "TS3_03_Date_DT": "20021231",
                "TS3_04_Quantity_R": "1",
                "TS3_05_MonetaryAmount_R": "211366.97",
                "TS3_06_MonetaryAmount_R": null,
                "TS3_07_MonetaryAmount_R": null,
                "TS3_08_MonetaryAmount_R": null,
                "TS3_09_MonetaryAmount_R": "138018.4",
                "TS3_10_MonetaryAmount_R": null,
                "TS3_11_MonetaryAmount_R": "73348.57",
                "TS3_12_MonetaryAmount_R": null,
                "TS3_13_MonetaryAmount_R": null,
                "TS3_14_MonetaryAmount_R": null,
                "TS3_15_MonetaryAmount_R": null,
                "TS3_16_MonetaryAmount_R": null,
                "TS3_17_MonetaryAmount_R": null,
                "TS3_18_MonetaryAmount_R": null,
                "TS3_19_MonetaryAmount_R": null,
                "TS3_20_MonetaryAmount_R": null,
                "TS3_21_MonetaryAmount_R": null,
                "TS3_22_MonetaryAmount_R": null,
                "TS3_23_Quantity_R": null,
                "TS3_24_MonetaryAmount_R": null
              },
              "ProviderSupplementalSummaryInformation": {
                "TS2_01_MonetaryAmount_R": "2178.45",
                "TS2_02_MonetaryAmount_R": "1919.71",
                "TS2_03_MonetaryAmount_R": null,
                "TS2_04_MonetaryAmount_R": "56.82",
                "TS2_05_MonetaryAmount_R": "197.69",
                "TS2_06_MonetaryAmount_R": "4.23",
                "TS2_07_Quantity_R": null,
                "TS2_08_MonetaryAmount_R": null,
                "TS2_09_MonetaryAmount_R": null,
                "TS2_10_Quantity_R": null,
                "TS2_11_Quantity_R": null,
                "TS2_12_Quantity_R": null,
                "TS2_13_Quantity_R": null,
                "TS2_14_Quantity_R": null,
                "TS2_15_MonetaryAmount_R": null,
                "TS2_16_Quantity_R": null,
                "TS2_17_MonetaryAmount_R": null,
                "TS2_18_MonetaryAmount_R": null,
                "TS2_19_MonetaryAmount_R": null
              },
              "ClaimPaymentInformation_Loop_2100": [
                {
                  "ClaimPaymentInformation": {
                    "CLP_01_ClaimSubmittersIdentifier_AN": "666123",
                    "CLP_02_ClaimStatusCode_ID": "1",
                    "CLP_03_MonetaryAmount_R": "211366.97",
                    "CLP_04_MonetaryAmount_R": "138018.4",
                    "CLP_05_MonetaryAmount_R": null,
                    "CLP_06_ClaimFilingIndicatorCode_ID": "MA",
                    "CLP_07_ReferenceIdentification_AN": "1999999444444",
                    "CLP_08_FacilityCodeValue_AN": "11",
                    "CLP_09_ClaimFrequencyTypeCode_ID": "1",
                    "CLP_10_PatientStatusCode_ID": null,
                    "CLP_11_DiagnosisRelatedGroupCode_ID": null,
                    "CLP_12_Quantity_R": null,
                    "CLP_13_PercentageAsDecimal_R": null,
                    "CLP_14_YesNoConditionOrResponseCode_ID": null
                  },
                  "ClaimAdjustment": [
                    {
                      "CAS_01_ClaimAdjustmentGroupCode_ID": "CO",
                      "CAS_02_ClaimAdjustmentReasonCode_ID": "45",
                      "CAS_03MonetaryAmount_R": "73348.57",
                      "CAS_04_Quantity_R": null,
                      "CAS_05_ClaimAdjustmentReasonCode_ID": null,
                      "CAS_06_MonetaryAmount_R": null,
                      "CAS_07_Quantity_R": null,
                      "CAS_08_ClaimAdjustmentReasonCode_ID": null,
                      "CAS_09_MonetaryAmount_R": null,
                      "CAS_10_Quantity_R": null,
                      "CAS_11_ClaimAdjustmentReasonCode_ID": null,
                      "CAS_12_MonetaryAmount_R": null,
                      "CAS_13_Quantity_R": null,
                      "CAS_14_ClaimAdjustmentReasonCode_ID": null,
                      "CAS_15_MonetaryAmount_R": null,
                      "CAS_16_Quantity_R": null,
                      "CAS_17_ClaimAdjustmentReasonCode_ID": null,
                      "CAS_18_MonetaryAmount_R": null,
                      "CAS_19_Quantity_R": null
                    }
                  ],
                  "PatientName": {
                    "NM1_01_EntityIdentifierCode_ID": "QC",
                    "NM1_02_EntityTypeQualifier_ID": "1",
                    "NM1_03_NameLastOrOrganizationName_AN": "JONES",
                    "NM1_04_NameFirst_AN": "SAM",
                    "NM1_05_NameMiddle_AN": "O",
                    "NM1_06_NamePrefix_AN": null,
                    "NM1_07_NameSuffix_AN": null,
                    "NM1_08_IdentificationCodeQualifier_ID": "HN",
                    "NM1_09_IdentificationCode_AN": "666666666A",
                    "NM1_10_EntityRelationshipCode_ID": null,
                    "NM1_11_EntityIdentifierCode_ID": null,
                    "NM1_12_NameLastOrOrganizationName_AN": null
                  },
                  "InsuredName": null,
                  "CorrectedPatientInsuredName": null,
                  "ServiceProviderName": null,
                  "CrossoverCarrierName": null,
                  "CorrectedPriorityPayerName": null,
                  "OtherSubscriberName": null,
                  "InpatientAdjudicationInformation": {
                    "MIA_01_Quantity_R": "0",
                    "MIA_02_MonetaryAmount_R": null,
                    "MIA_03_Quantity_R": null,
                    "MIA_04_MonetaryAmount_R": "138018.4",
                    "MIA_05_ReferenceIdentification_AN": null,
                    "MIA_06_MonetaryAmount_R": null,
                    "MIA_07_MonetaryAmount_R": null,
                    "MIA_08_MonetaryAmount_R": null,
                    "MIA_09_MonetaryAmount_R": null,
                    "MIA_10_MonetaryAmount_R": null,
                    "MIA_11_MonetaryAmount_R": null,
                    "MIA_12_MonetaryAmount_R": null,
                    "MIA_13_MonetaryAmount_R": null,
                    "MIA_14_MonetaryAmount_R": null,
                    "MIA_15_Quantity_R": null,
                    "MIA_16_MonetaryAmount_R": null,
                    "MIA_17_MonetaryAmount_R": null,
                    "MIA_18_MonetaryAmount_R": null,
                    "MIA_19_MonetaryAmount_R": null,
                    "MIA_20_ReferenceIdentification_AN": null,
                    "MIA_21_ReferenceIdentification_AN": null,
                    "MIA_22_ReferenceIdentification_AN": null,
                    "MIA_23_ReferenceIdentification_AN": null,
                    "MIA_24_MonetaryAmount_R": null
                  },
                  "OutpatientAdjudicationInformation": null,
                  "OtherClaimRelatedIdentification": null,
                  "RenderingProviderIdentification": null,
                  "StatementFromOrToDate": [
                    {
                      "DTM_01_DateTimeQualifier_ID": "232",
                      "DTM_02_Date_DT": "20020816",
                      "DTM_03_Time_TM": null,
                      "DTM_04_TimeCode_ID": null,
                      "DTM_05_DateTimePeriodFormatQualifier_ID": null,
                      "DTM_06_DateTimePeriod_AN": null
                    },
                    {
                      "DTM_01_DateTimeQualifier_ID": "233",
                      "DTM_02_Date_DT": "20020824",
                      "DTM_03_Time_TM": null,
                      "DTM_04_TimeCode_ID": null,
                      "DTM_05_DateTimePeriodFormatQualifier_ID": null,
                      "DTM_06_DateTimePeriod_AN": null
                    }
                  ],
                  "CoverageExpirationDate": null,
                  "ClaimReceivedDate": null,
                  "ClaimContactInformation": null,
                  "ClaimSupplementalInformation": null,
                  "ClaimSupplementalInformationQuantity": [
                    {
                      "QTY_01_QuantityQualifier_ID": "CA",
                      "QTY_02_Quantity_R": "8",
                      "QTY_03_CompositeUnitOfMeasure": null,
                      "QTY_04_FreeFormInformation_AN": null
                    }
                  ],
                  "ServicePaymentInformation_Loop_2110": [
                    {
                      "ServicePaymentInformation": null,
                      "ServiceDate": null,
                      "ServiceAdjustment": null,
                      "ServiceIdentification": null,
                      "LineItemControlNumber": null,
                      "RenderingProviderInformation": null,
                      "HealthCarePolicyIdentification": null,
                      "ServiceSupplementalAmount": null,
                      "ServiceSupplementalQuantity": null,
                      "HealthCareRemarkCodes": null
                    }
                  ]
                }
              ]
            },
            {
              "HeaderNumber": {
                "LX_01_AssignedNumber_N": "130212"
              },
              "ProviderSummaryInformation": {
                "TS3_01_ReferenceIdentification_AN": "6543210909",
                "TS3_02_FacilityCodeValue_AN": "13",
                "TS3_03_Date_DT": "19961231",
                "TS3_04_Quantity_R": "1",
                "TS3_05_MonetaryAmount_R": "15000",
                "TS3_06_MonetaryAmount_R": null,
                "TS3_07_MonetaryAmount_R": null,
                "TS3_08_MonetaryAmount_R": null,
                "TS3_09_MonetaryAmount_R": "11980.33",
                "TS3_10_MonetaryAmount_R": null,
                "TS3_11_MonetaryAmount_R": "3019.67",
                "TS3_12_MonetaryAmount_R": null,
                "TS3_13_MonetaryAmount_R": null,
                "TS3_14_MonetaryAmount_R": null,
                "TS3_15_MonetaryAmount_R": null,
                "TS3_16_MonetaryAmount_R": null,
                "TS3_17_MonetaryAmount_R": null,
                "TS3_18_MonetaryAmount_R": null,
                "TS3_19_MonetaryAmount_R": null,
                "TS3_20_MonetaryAmount_R": null,
                "TS3_21_MonetaryAmount_R": null,
                "TS3_22_MonetaryAmount_R": null,
                "TS3_23_Quantity_R": null,
                "TS3_24_MonetaryAmount_R": null
              },
              "ProviderSupplementalSummaryInformation": null,
              "ClaimPaymentInformation_Loop_2100": [
                {
                  "ClaimPaymentInformation": {
                    "CLP_01_ClaimSubmittersIdentifier_AN": "777777",
                    "CLP_02_ClaimStatusCode_ID": "1",
                    "CLP_03_MonetaryAmount_R": "15000",
                    "CLP_04_MonetaryAmount_R": "11980.33",
                    "CLP_05_MonetaryAmount_R": null,
                    "CLP_06_ClaimFilingIndicatorCode_ID": "MB",
                    "CLP_07_ReferenceIdentification_AN": "1999999444445",
                    "CLP_08_FacilityCodeValue_AN": "13",
                    "CLP_09_ClaimFrequencyTypeCode_ID": "1",
                    "CLP_10_PatientStatusCode_ID": null,
                    "CLP_11_DiagnosisRelatedGroupCode_ID": null,
                    "CLP_12_Quantity_R": null,
                    "CLP_13_PercentageAsDecimal_R": null,
                    "CLP_14_YesNoConditionOrResponseCode_ID": null
                  },
                  "ClaimAdjustment": [
                    {
                      "CAS_01_ClaimAdjustmentGroupCode_ID": "CO",
                      "CAS_02_ClaimAdjustmentReasonCode_ID": "45",
                      "CAS_03MonetaryAmount_R": "3019.67",
                      "CAS_04_Quantity_R": null,
                      "CAS_05_ClaimAdjustmentReasonCode_ID": null,
                      "CAS_06_MonetaryAmount_R": null,
                      "CAS_07_Quantity_R": null,
                      "CAS_08_ClaimAdjustmentReasonCode_ID": null,
                      "CAS_09_MonetaryAmount_R": null,
                      "CAS_10_Quantity_R": null,
                      "CAS_11_ClaimAdjustmentReasonCode_ID": null,
                      "CAS_12_MonetaryAmount_R": null,
                      "CAS_13_Quantity_R": null,
                      "CAS_14_ClaimAdjustmentReasonCode_ID": null,
                      "CAS_15_MonetaryAmount_R": null,
                      "CAS_16_Quantity_R": null,
                      "CAS_17_ClaimAdjustmentReasonCode_ID": null,
                      "CAS_18_MonetaryAmount_R": null,
                      "CAS_19_Quantity_R": null
                    }
                  ],
                  "PatientName": {
                    "NM1_01_EntityIdentifierCode_ID": "QC",
                    "NM1_02_EntityTypeQualifier_ID": "1",
                    "NM1_03_NameLastOrOrganizationName_AN": "BORDER",
                    "NM1_04_NameFirst_AN": "LIZ",
                    "NM1_05_NameMiddle_AN": "E",
                    "NM1_06_NamePrefix_AN": null,
                    "NM1_07_NameSuffix_AN": null,
                    "NM1_08_IdentificationCodeQualifier_ID": "HN",
                    "NM1_09_IdentificationCode_AN": "996669999B",
                    "NM1_10_EntityRelationshipCode_ID": null,
                    "NM1_11_EntityIdentifierCode_ID": null,
                    "NM1_12_NameLastOrOrganizationName_AN": null
                  },
                  "InsuredName": null,
                  "CorrectedPatientInsuredName": null,
                  "ServiceProviderName": null,
                  "CrossoverCarrierName": null,
                  "CorrectedPriorityPayerName": null,
                  "OtherSubscriberName": null,
                  "InpatientAdjudicationInformation": null,
                  "OutpatientAdjudicationInformation": {
                    "MOA_01_PercentageAsDecimal_R": null,
                    "MOA_02_MonetaryAmount_R": null,
                    "MOA_03_ReferenceIdentification_AN": "MA02",
                    "MOA_04_ReferenceIdentification_AN": null,
                    "MOA_05_ReferenceIdentification_AN": null,
                    "MOA_06_ReferenceIdentification_AN": null,
                    "MOA_07_referenceIdentification_AN": null,
                    "MOA_08_MonetaryAmount_R": null,
                    "MOA_09_MonetaryAmount_R": null
                  },
                  "OtherClaimRelatedIdentification": null,
                  "RenderingProviderIdentification": null,
                  "StatementFromOrToDate": [
                    {
                      "DTM_01_DateTimeQualifier_ID": "232",
                      "DTM_02_Date_DT": "20020512",
                      "DTM_03_Time_TM": null,
                      "DTM_04_TimeCode_ID": null,
                      "DTM_05_DateTimePeriodFormatQualifier_ID": null,
                      "DTM_06_DateTimePeriod_AN": null
                    }
                  ],
                  "CoverageExpirationDate": null,
                  "ClaimReceivedDate": null,
                  "ClaimContactInformation": null,
                  "ClaimSupplementalInformation": null,
                  "ClaimSupplementalInformationQuantity": null,
                  "ServicePaymentInformation_Loop_2110": [
                    {
                      "ServicePaymentInformation": null,
                      "ServiceDate": null,
                      "ServiceAdjustment": null,
                      "ServiceIdentification": null,
                      "LineItemControlNumber": null,
                      "RenderingProviderInformation": null,
                      "HealthCarePolicyIdentification": null,
                      "ServiceSupplementalAmount": null,
                      "ServiceSupplementalQuantity": null,
                      "HealthCareRemarkCodes": null
                    }
                  ]
                }
              ]
            }
          ],
          "ProviderAdjustment": [
            {
              "PLB_01_ReferenceIdentification_AN": "6543210903",
              "PLB_02_Date_DT": "20021231",
              "PLB_03_AdjustmentIdentifier": {
                "C042_01_AdjustmentReasonCode_ID": "CV",
                "C042_02_ReferenceIdentification_AN": "CP"
              },
              "PLB_04_MonetaryAmount_R": "-1.27",
              "PLB_05_AdjustmentIdentifier": null,
              "PLB_06_MonetaryAmount_R": null,
              "PLB_07_AdjustmentIdentifier": null,
              "PLB_08_MonetaryAmount_R": null,
              "PLB_09_AdjustmentIdentifier": null,
              "PLB_10_MonetaryAmount_R": null,
              "PLB_11_AdjustmentIdentifier": null,
              "PLB_12_MonetaryAmount_R": null,
              "PLB_13_AdjustmentIdentifier": null,
              "PLB_14_MonetaryAmount_R": null
            }
          ],
          "TransactionSetTrailer": {
            "SE_01_NumberOfIncludedSegments_N": "28",
            "SE_02_TransactionSetControlNumber_AN": "1234"
          }
        }
      ],
      "FunctionalGroupTrailerSegment": {
        "GE_01_NumberOfTransactionSetsIncluded_N": "1",
        "GE_02_GroupControlNumber_N": "1"
      }
    }
  ],
  "InterchangeControlTrailerSegment": {
    "IEA_01_NumberOfIncludedFunctionalGroups_N": "1",
    "IEA_02_InterchangeControlNumber_N": "000000001"
  }
}

JSON Request to EDI 835 Response

Transforms JSON into an EDI 835 message.

post https://api-edi.splinxtechnologies.com/v1/edi-transformation/json-to-edi835

Request headers

Authentication

To make REST API calls, make sure to include your account's email and password in a Base64 encrypted format in the Basic authentication scheme. The value is <Account-Email> and <Account-Password>

LicenseId

Sample request

JSON Copy

{
  "InterchangeControlHeaderSegment": {
    "ISA_01_AuthorizationInformationQualifier_ID": "00",
    "ISA_02_AuthorizationInformation_AN": "          ",
    "ISA_03_SecurityInformationQualifier_ID": "00",
    "ISA_04_SecurityInformation_AN": "          ",
    "ISA_05_InterchangeIDQualifier_ID": "ZZ",
    "ISA_06_InterchangeSenderID_AN": "SUBMITTERS ID  ",
    "ISA_07_InterchangeIDQualifier_ID": "ZZ",
    "ISA_08_InterchangeReceiverID_AN": "RECEIVERS ID   ",
    "ISA_09_InterchangeDate_DT": "220412",
    "ISA_10_InterchangeTime_TM": "1253",
    "ISA_11_RepetitionSeparator": "^",
    "ISA_12_InterchangeControlVersionNumber_ID": "00501",
    "ISA_13_InterchangeControlNumber_N": "000000001",
    "ISA_14_AcknowledgmentRequest_ID": "0",
    "ISA_15_InterchangeUsageIndicator_ID": "P",
    "ISA_16_ComponentElementSeparator": ":"
  },
  "FunctionalGroups": [
    {
      "FunctionalGroupHeaderSegment": {
        "GS_01_FunctionalIdentifierCode_ID": "XX",
        "GS_02_ApplicationSendersCode_AN": "SENDER CODE",
        "GS_03_ApplicationReceiversCode_AN": "RECEIVERCODE",
        "GS_04_Date_DT": "20220412",
        "GS_05_Time_TM": "1513",
        "GS_06_GroupControlNumber_N": "1",
        "GS_07_ResponsibleAgencyCode_ID": "X",
        "GS_08_VersionReleaseIndustryIdentifierCode_AN": "005010X221A1"
      },
      "TransactionSets": [
        {
          "TransactionSetHeader": {
            "ST_01_TransactionSetIdentifierCode_ID": "835",
            "ST_02_TransactionSetControlNumber_AN": "1234",
            "ST_03_ImplementationConventionReference_AN": null
          },
          "FinancialInformation": {
            "BPR_01_TransactionHandlingCode_ID": "C",
            "BPR_02_MonetaryAmount_R": "150000",
            "BPR_03_CreditDebitFlagCode_ID": "C",
            "BPR_04_PaymentMethodCode_ID": "ACH",
            "BPR_05_PaymentFormatCode_ID": "CTX",
            "BPR_06_DfiIdNumberQualifier_ID": "01",
            "BPR_07_DfiIdentificationNumber_AN": "999999992",
            "BPR_08_AccountNumberQualifier_ID": "DA",
            "BPR_09_AccountNumber_AN": "123456",
            "BPR_10_OriginatingCompanyIdentifier_AN": "1512345678",
            "BPR_11_OriginatingCompanySupplementalCode_AN": null,
            "BPR_12_DfiIdNumberQualifier_ID": "01",
            "BPR_13_DfiIdentificationNumber_AN": "999988880",
            "BPR_14_AccountNumberQualifier_ID": "DA",
            "BPR_15_AccountNumber_AN": "98765",
            "BPR_16_Date_DT": "20020913",
            "BPR_17_BusinessFunctionCode_ID": null,
            "BPR_18_DfiIdNumberQualifier_ID": null,
            "BPR_19_DfiIdentificationNumber_AN": null,
            "BPR_20_AccountNumberQualifier_ID": null,
            "BPR_21_AccountNumber_AN": null
          },
          "ReassociationTraceNumber": {
            "TRN_01_TraceTypeCode_ID": "1",
            "TRN_02_ReferenceIdentification_AN": "12345",
            "TRN_03_OriginatingCompanyIdentifier_AN": "1512345678",
            "TRN_04_ReferenceIdentification_AN": null
          },
          "ForeignCurrencyInformation": null,
          "ReceiverIdentification": null,
          "VersionIdentification": null,
          "ProductionDate": {
            "DTM_01_DateTimeQualifier_ID": "405",
            "DTM_02_Date_DT": "20020916",
            "DTM_03_Time_TM": null,
            "DTM_04_TimeCode_ID": null,
            "DTM_05_DateTimePeriodFormatQualifier_ID": null,
            "DTM_06_DateTimePeriod_AN": null
          },
          "PayerIdentification_Loop_1000A": {
            "PayerIdentification": {
              "N1_01_EntityIdentifierCode_ID": "PR",
              "N1_02_Name_AN": "INSURANCE COMPANY OF TIMBUCKTU",
              "N1_03_IdentificationCodeQualifier_ID": null,
              "N1_04_IdentificationCode_AN": null,
              "N1_05_EntityRelationshipCode_ID": null,
              "N1_06_EntityIdentifierCode_ID": null
            },
            "PayerAddress": {
              "N3_01_AddressInformation_AN": "1 MAIN STREET",
              "N3_02_AddressInformation_AN": null
            },
            "PayerCityStateZipCode": {
              "N4_01_CityName_AN": "TIMBUCKTU",
              "N4_02_StateOrProvinceCode_ID": "AK",
              "N4_03_PostalCode_ID": "89111",
              "N4_04_CountryCode_ID": null,
              "N4_05_LocationQualifier_ID": null,
              "N4_06_LocationIdentifier_AN": null,
              "N4_07_CountrySubdivisionCode_ID": null
            },
            "AdditionalPayerIdentification": [
              {
                "REF_01_ReferenceIdentificationQualifier_ID": "2U",
                "REF_02_ReferenceIdentification_AN": "999",
                "REF_03_Description_AN": null,
                "REF_04_ReferenceIdentifier": null
              }
            ],
            "PayerBusinessContactInformation": null,
            "PayerTechnicalContactInformation": null,
            "PayerWebSite": null
          },
          "PayeeIdentification_Loop_1000B": {
            "PayeeIdentification": {
              "N1_01_EntityIdentifierCode_ID": "PE",
              "N1_02_Name_AN": "REGIONAL HOPE HOSPITAL",
              "N1_03_IdentificationCodeQualifier_ID": "XX",
              "N1_04_IdentificationCode_AN": "6543210903",
              "N1_05_EntityRelationshipCode_ID": null,
              "N1_06_EntityIdentifierCode_ID": null
            },
            "PayeeAddress": null,
            "PayeeCityStateZipCode": null,
            "PayeeAdditionalIdentification": null,
            "RemittanceDeliveryMethod": null
          },
          "HeaderNumber_Loop_2000": [
            {
              "HeaderNumber": {
                "LX_01_AssignedNumber_N": "110212"
              },
              "ProviderSummaryInformation": {
                "TS3_01_ReferenceIdentification_AN": "6543210903",
                "TS3_02_FacilityCodeValue_AN": "11",
                "TS3_03_Date_DT": "20021231",
                "TS3_04_Quantity_R": "1",
                "TS3_05_MonetaryAmount_R": "211366.97",
                "TS3_06_MonetaryAmount_R": null,
                "TS3_07_MonetaryAmount_R": null,
                "TS3_08_MonetaryAmount_R": null,
                "TS3_09_MonetaryAmount_R": "138018.4",
                "TS3_10_MonetaryAmount_R": null,
                "TS3_11_MonetaryAmount_R": "73348.57",
                "TS3_12_MonetaryAmount_R": null,
                "TS3_13_MonetaryAmount_R": null,
                "TS3_14_MonetaryAmount_R": null,
                "TS3_15_MonetaryAmount_R": null,
                "TS3_16_MonetaryAmount_R": null,
                "TS3_17_MonetaryAmount_R": null,
                "TS3_18_MonetaryAmount_R": null,
                "TS3_19_MonetaryAmount_R": null,
                "TS3_20_MonetaryAmount_R": null,
                "TS3_21_MonetaryAmount_R": null,
                "TS3_22_MonetaryAmount_R": null,
                "TS3_23_Quantity_R": null,
                "TS3_24_MonetaryAmount_R": null
              },
              "ProviderSupplementalSummaryInformation": {
                "TS2_01_MonetaryAmount_R": "2178.45",
                "TS2_02_MonetaryAmount_R": "1919.71",
                "TS2_03_MonetaryAmount_R": null,
                "TS2_04_MonetaryAmount_R": "56.82",
                "TS2_05_MonetaryAmount_R": "197.69",
                "TS2_06_MonetaryAmount_R": "4.23",
                "TS2_07_Quantity_R": null,
                "TS2_08_MonetaryAmount_R": null,
                "TS2_09_MonetaryAmount_R": null,
                "TS2_10_Quantity_R": null,
                "TS2_11_Quantity_R": null,
                "TS2_12_Quantity_R": null,
                "TS2_13_Quantity_R": null,
                "TS2_14_Quantity_R": null,
                "TS2_15_MonetaryAmount_R": null,
                "TS2_16_Quantity_R": null,
                "TS2_17_MonetaryAmount_R": null,
                "TS2_18_MonetaryAmount_R": null,
                "TS2_19_MonetaryAmount_R": null
              },
              "ClaimPaymentInformation_Loop_2100": [
                {
                  "ClaimPaymentInformation": {
                    "CLP_01_ClaimSubmittersIdentifier_AN": "666123",
                    "CLP_02_ClaimStatusCode_ID": "1",
                    "CLP_03_MonetaryAmount_R": "211366.97",
                    "CLP_04_MonetaryAmount_R": "138018.4",
                    "CLP_05_MonetaryAmount_R": null,
                    "CLP_06_ClaimFilingIndicatorCode_ID": "MA",
                    "CLP_07_ReferenceIdentification_AN": "1999999444444",
                    "CLP_08_FacilityCodeValue_AN": "11",
                    "CLP_09_ClaimFrequencyTypeCode_ID": "1",
                    "CLP_10_PatientStatusCode_ID": null,
                    "CLP_11_DiagnosisRelatedGroupCode_ID": null,
                    "CLP_12_Quantity_R": null,
                    "CLP_13_PercentageAsDecimal_R": null,
                    "CLP_14_YesNoConditionOrResponseCode_ID": null
                  },
                  "ClaimAdjustment": [
                    {
                      "CAS_01_ClaimAdjustmentGroupCode_ID": "CO",
                      "CAS_02_ClaimAdjustmentReasonCode_ID": "45",
                      "CAS_03MonetaryAmount_R": "73348.57",
                      "CAS_04_Quantity_R": null,
                      "CAS_05_ClaimAdjustmentReasonCode_ID": null,
                      "CAS_06_MonetaryAmount_R": null,
                      "CAS_07_Quantity_R": null,
                      "CAS_08_ClaimAdjustmentReasonCode_ID": null,
                      "CAS_09_MonetaryAmount_R": null,
                      "CAS_10_Quantity_R": null,
                      "CAS_11_ClaimAdjustmentReasonCode_ID": null,
                      "CAS_12_MonetaryAmount_R": null,
                      "CAS_13_Quantity_R": null,
                      "CAS_14_ClaimAdjustmentReasonCode_ID": null,
                      "CAS_15_MonetaryAmount_R": null,
                      "CAS_16_Quantity_R": null,
                      "CAS_17_ClaimAdjustmentReasonCode_ID": null,
                      "CAS_18_MonetaryAmount_R": null,
                      "CAS_19_Quantity_R": null
                    }
                  ],
                  "PatientName": {
                    "NM1_01_EntityIdentifierCode_ID": "QC",
                    "NM1_02_EntityTypeQualifier_ID": "1",
                    "NM1_03_NameLastOrOrganizationName_AN": "JONES",
                    "NM1_04_NameFirst_AN": "SAM",
                    "NM1_05_NameMiddle_AN": "O",
                    "NM1_06_NamePrefix_AN": null,
                    "NM1_07_NameSuffix_AN": null,
                    "NM1_08_IdentificationCodeQualifier_ID": "HN",
                    "NM1_09_IdentificationCode_AN": "666666666A",
                    "NM1_10_EntityRelationshipCode_ID": null,
                    "NM1_11_EntityIdentifierCode_ID": null,
                    "NM1_12_NameLastOrOrganizationName_AN": null
                  },
                  "InsuredName": null,
                  "CorrectedPatientInsuredName": null,
                  "ServiceProviderName": null,
                  "CrossoverCarrierName": null,
                  "CorrectedPriorityPayerName": null,
                  "OtherSubscriberName": null,
                  "InpatientAdjudicationInformation": {
                    "MIA_01_Quantity_R": "0",
                    "MIA_02_MonetaryAmount_R": null,
                    "MIA_03_Quantity_R": null,
                    "MIA_04_MonetaryAmount_R": "138018.4",
                    "MIA_05_ReferenceIdentification_AN": null,
                    "MIA_06_MonetaryAmount_R": null,
                    "MIA_07_MonetaryAmount_R": null,
                    "MIA_08_MonetaryAmount_R": null,
                    "MIA_09_MonetaryAmount_R": null,
                    "MIA_10_MonetaryAmount_R": null,
                    "MIA_11_MonetaryAmount_R": null,
                    "MIA_12_MonetaryAmount_R": null,
                    "MIA_13_MonetaryAmount_R": null,
                    "MIA_14_MonetaryAmount_R": null,
                    "MIA_15_Quantity_R": null,
                    "MIA_16_MonetaryAmount_R": null,
                    "MIA_17_MonetaryAmount_R": null,
                    "MIA_18_MonetaryAmount_R": null,
                    "MIA_19_MonetaryAmount_R": null,
                    "MIA_20_ReferenceIdentification_AN": null,
                    "MIA_21_ReferenceIdentification_AN": null,
                    "MIA_22_ReferenceIdentification_AN": null,
                    "MIA_23_ReferenceIdentification_AN": null,
                    "MIA_24_MonetaryAmount_R": null
                  },
                  "OutpatientAdjudicationInformation": null,
                  "OtherClaimRelatedIdentification": null,
                  "RenderingProviderIdentification": null,
                  "StatementFromOrToDate": [
                    {
                      "DTM_01_DateTimeQualifier_ID": "232",
                      "DTM_02_Date_DT": "20020816",
                      "DTM_03_Time_TM": null,
                      "DTM_04_TimeCode_ID": null,
                      "DTM_05_DateTimePeriodFormatQualifier_ID": null,
                      "DTM_06_DateTimePeriod_AN": null
                    },
                    {
                      "DTM_01_DateTimeQualifier_ID": "233",
                      "DTM_02_Date_DT": "20020824",
                      "DTM_03_Time_TM": null,
                      "DTM_04_TimeCode_ID": null,
                      "DTM_05_DateTimePeriodFormatQualifier_ID": null,
                      "DTM_06_DateTimePeriod_AN": null
                    }
                  ],
                  "CoverageExpirationDate": null,
                  "ClaimReceivedDate": null,
                  "ClaimContactInformation": null,
                  "ClaimSupplementalInformation": null,
                  "ClaimSupplementalInformationQuantity": [
                    {
                      "QTY_01_QuantityQualifier_ID": "CA",
                      "QTY_02_Quantity_R": "8",
                      "QTY_03_CompositeUnitOfMeasure": null,
                      "QTY_04_FreeFormInformation_AN": null
                    }
                  ],
                  "ServicePaymentInformation_Loop_2110": [
                    {
                      "ServicePaymentInformation": null,
                      "ServiceDate": null,
                      "ServiceAdjustment": null,
                      "ServiceIdentification": null,
                      "LineItemControlNumber": null,
                      "RenderingProviderInformation": null,
                      "HealthCarePolicyIdentification": null,
                      "ServiceSupplementalAmount": null,
                      "ServiceSupplementalQuantity": null,
                      "HealthCareRemarkCodes": null
                    }
                  ]
                }
              ]
            },
            {
              "HeaderNumber": {
                "LX_01_AssignedNumber_N": "130212"
              },
              "ProviderSummaryInformation": {
                "TS3_01_ReferenceIdentification_AN": "6543210909",
                "TS3_02_FacilityCodeValue_AN": "13",
                "TS3_03_Date_DT": "19961231",
                "TS3_04_Quantity_R": "1",
                "TS3_05_MonetaryAmount_R": "15000",
                "TS3_06_MonetaryAmount_R": null,
                "TS3_07_MonetaryAmount_R": null,
                "TS3_08_MonetaryAmount_R": null,
                "TS3_09_MonetaryAmount_R": "11980.33",
                "TS3_10_MonetaryAmount_R": null,
                "TS3_11_MonetaryAmount_R": "3019.67",
                "TS3_12_MonetaryAmount_R": null,
                "TS3_13_MonetaryAmount_R": null,
                "TS3_14_MonetaryAmount_R": null,
                "TS3_15_MonetaryAmount_R": null,
                "TS3_16_MonetaryAmount_R": null,
                "TS3_17_MonetaryAmount_R": null,
                "TS3_18_MonetaryAmount_R": null,
                "TS3_19_MonetaryAmount_R": null,
                "TS3_20_MonetaryAmount_R": null,
                "TS3_21_MonetaryAmount_R": null,
                "TS3_22_MonetaryAmount_R": null,
                "TS3_23_Quantity_R": null,
                "TS3_24_MonetaryAmount_R": null
              },
              "ProviderSupplementalSummaryInformation": null,
              "ClaimPaymentInformation_Loop_2100": [
                {
                  "ClaimPaymentInformation": {
                    "CLP_01_ClaimSubmittersIdentifier_AN": "777777",
                    "CLP_02_ClaimStatusCode_ID": "1",
                    "CLP_03_MonetaryAmount_R": "15000",
                    "CLP_04_MonetaryAmount_R": "11980.33",
                    "CLP_05_MonetaryAmount_R": null,
                    "CLP_06_ClaimFilingIndicatorCode_ID": "MB",
                    "CLP_07_ReferenceIdentification_AN": "1999999444445",
                    "CLP_08_FacilityCodeValue_AN": "13",
                    "CLP_09_ClaimFrequencyTypeCode_ID": "1",
                    "CLP_10_PatientStatusCode_ID": null,
                    "CLP_11_DiagnosisRelatedGroupCode_ID": null,
                    "CLP_12_Quantity_R": null,
                    "CLP_13_PercentageAsDecimal_R": null,
                    "CLP_14_YesNoConditionOrResponseCode_ID": null
                  },
                  "ClaimAdjustment": [
                    {
                      "CAS_01_ClaimAdjustmentGroupCode_ID": "CO",
                      "CAS_02_ClaimAdjustmentReasonCode_ID": "45",
                      "CAS_03MonetaryAmount_R": "3019.67",
                      "CAS_04_Quantity_R": null,
                      "CAS_05_ClaimAdjustmentReasonCode_ID": null,
                      "CAS_06_MonetaryAmount_R": null,
                      "CAS_07_Quantity_R": null,
                      "CAS_08_ClaimAdjustmentReasonCode_ID": null,
                      "CAS_09_MonetaryAmount_R": null,
                      "CAS_10_Quantity_R": null,
                      "CAS_11_ClaimAdjustmentReasonCode_ID": null,
                      "CAS_12_MonetaryAmount_R": null,
                      "CAS_13_Quantity_R": null,
                      "CAS_14_ClaimAdjustmentReasonCode_ID": null,
                      "CAS_15_MonetaryAmount_R": null,
                      "CAS_16_Quantity_R": null,
                      "CAS_17_ClaimAdjustmentReasonCode_ID": null,
                      "CAS_18_MonetaryAmount_R": null,
                      "CAS_19_Quantity_R": null
                    }
                  ],
                  "PatientName": {
                    "NM1_01_EntityIdentifierCode_ID": "QC",
                    "NM1_02_EntityTypeQualifier_ID": "1",
                    "NM1_03_NameLastOrOrganizationName_AN": "BORDER",
                    "NM1_04_NameFirst_AN": "LIZ",
                    "NM1_05_NameMiddle_AN": "E",
                    "NM1_06_NamePrefix_AN": null,
                    "NM1_07_NameSuffix_AN": null,
                    "NM1_08_IdentificationCodeQualifier_ID": "HN",
                    "NM1_09_IdentificationCode_AN": "996669999B",
                    "NM1_10_EntityRelationshipCode_ID": null,
                    "NM1_11_EntityIdentifierCode_ID": null,
                    "NM1_12_NameLastOrOrganizationName_AN": null
                  },
                  "InsuredName": null,
                  "CorrectedPatientInsuredName": null,
                  "ServiceProviderName": null,
                  "CrossoverCarrierName": null,
                  "CorrectedPriorityPayerName": null,
                  "OtherSubscriberName": null,
                  "InpatientAdjudicationInformation": null,
                  "OutpatientAdjudicationInformation": {
                    "MOA_01_PercentageAsDecimal_R": null,
                    "MOA_02_MonetaryAmount_R": null,
                    "MOA_03_ReferenceIdentification_AN": "MA02",
                    "MOA_04_ReferenceIdentification_AN": null,
                    "MOA_05_ReferenceIdentification_AN": null,
                    "MOA_06_ReferenceIdentification_AN": null,
                    "MOA_07_referenceIdentification_AN": null,
                    "MOA_08_MonetaryAmount_R": null,
                    "MOA_09_MonetaryAmount_R": null
                  },
                  "OtherClaimRelatedIdentification": null,
                  "RenderingProviderIdentification": null,
                  "StatementFromOrToDate": [
                    {
                      "DTM_01_DateTimeQualifier_ID": "232",
                      "DTM_02_Date_DT": "20020512",
                      "DTM_03_Time_TM": null,
                      "DTM_04_TimeCode_ID": null,
                      "DTM_05_DateTimePeriodFormatQualifier_ID": null,
                      "DTM_06_DateTimePeriod_AN": null
                    }
                  ],
                  "CoverageExpirationDate": null,
                  "ClaimReceivedDate": null,
                  "ClaimContactInformation": null,
                  "ClaimSupplementalInformation": null,
                  "ClaimSupplementalInformationQuantity": null,
                  "ServicePaymentInformation_Loop_2110": [
                    {
                      "ServicePaymentInformation": null,
                      "ServiceDate": null,
                      "ServiceAdjustment": null,
                      "ServiceIdentification": null,
                      "LineItemControlNumber": null,
                      "RenderingProviderInformation": null,
                      "HealthCarePolicyIdentification": null,
                      "ServiceSupplementalAmount": null,
                      "ServiceSupplementalQuantity": null,
                      "HealthCareRemarkCodes": null
                    }
                  ]
                }
              ]
            }
          ],
          "ProviderAdjustment": [
            {
              "PLB_01_ReferenceIdentification_AN": "6543210903",
              "PLB_02_Date_DT": "20021231",
              "PLB_03_AdjustmentIdentifier": {
                "C042_01_AdjustmentReasonCode_ID": "CV",
                "C042_02_ReferenceIdentification_AN": "CP"
              },
              "PLB_04_MonetaryAmount_R": "-1.27",
              "PLB_05_AdjustmentIdentifier": null,
              "PLB_06_MonetaryAmount_R": null,
              "PLB_07_AdjustmentIdentifier": null,
              "PLB_08_MonetaryAmount_R": null,
              "PLB_09_AdjustmentIdentifier": null,
              "PLB_10_MonetaryAmount_R": null,
              "PLB_11_AdjustmentIdentifier": null,
              "PLB_12_MonetaryAmount_R": null,
              "PLB_13_AdjustmentIdentifier": null,
              "PLB_14_MonetaryAmount_R": null
            }
          ],
          "TransactionSetTrailer": {
            "SE_01_NumberOfIncludedSegments_N": "28",
            "SE_02_TransactionSetControlNumber_AN": "1234"
          }
        }
      ],
      "FunctionalGroupTrailerSegment": {
        "GE_01_NumberOfTransactionSetsIncluded_N": "1",
        "GE_02_GroupControlNumber_N": "1"
      }
    }
  ],
  "InterchangeControlTrailerSegment": {
    "IEA_01_NumberOfIncludedFunctionalGroups_N": "1",
    "IEA_02_InterchangeControlNumber_N": "000000001"
  }
}

Sample response

EDI 835 Copy

ISA*00*          *00*          *ZZ*SUBMITTERS ID  *ZZ*RECEIVERS ID   *220412*1253*^*00501*000000001*0*P*:~GS*XX*SENDER CODE*RECEIVERCODE*20220412*1513*1*X*005010X221A1~ST*835*1234~BPR*C*150000*C*ACH*CTX*01*999999992*DA*123456*1512345678**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~N1*PE*REGIONAL HOPE HOSPITAL*XX*6543210903~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*28*1234~GE*1*1~IEA*1*000000001~

Payer fields

Field

Description

Name

string

BusinessContactName

string

BuisnessContactInformation

List<ReferenceInformation> represents the business contact information for the payer. Use class ReferenceInformation for reference.

TechnicalContactInfomation

List<ContactAndReferenceInformation> represents the technical contact information for the payer. Use class ContactAndReferenceInformation for reference.

WebSiteUrl

string

AddressInformation

AddressInformation represents the address information. Use class AddressInformation for reference.

AdditionalIdentifiers

List<ReferenceInformation> represents any additional identifiers. Use class ReferenceInformation for reference.

ReferenceInformation fields

Field

Description

Identifier

string

IdentifierType

string

Description

string

ContactAndReferenceInformation fields

Field

Description

ContactName

string

ContactCommunicationInformation

List<ReferenceInformation> represents the contact communication information. Use class ReferenceInformation for reference.

AddressInformation fields

Field

Description

StreetAddress1

string

StreetAddress2

string

City

string

State

string

ZipCode

string

Payee fields

Field

Description

Name

string

TechnicalContactName

string

TechnicalContactCommunicationInformation

List<ReferenceInformation> represents the technical contact communication information for the payee. Use class ReferenceInformation for reference.

AddressInformation

AddressInformation represents the address information. Use class AddressInformation for reference.

AdditionalIdentifiers

List<ReferenceInformation> represents any additional identifiers. Use class ReferenceInformation for reference.

ClaimPaymentDetails fields

Field

Description

ProviderSummaryInfomation

ProviderSummaryInfomation represents the provider summary information. Use class ProviderSummaryInfomation for reference.

ClaimPaymentInformation

List<ClaimPaymentInformation> represents the claim payment information. Use class ClaimPaymentInformation for reference.

ProviderSummaryInfomation fields

Field

Description

ProviderIdentification

string

FiscalPeriodDate

string

NumberOfClaims

string

TotalClaimsCharges

string

TotalMedicareSecondaryPayerAmount

string

TotalNonLabChargeAmount

string

TotalHCPCSReportedChargeAmount

string

TotalHCPCSPayableAmount

string

TotalProfessionalComponentAmount

string

TotalMedicareSecondaryPayerPatientLiabilityNetAmount

string

TotalPatientReimbursementAmount

string

TotalPeriodicInterimPaymentClaimCount

string

TotalPeriodicInterimPaymentAmount

string

ClaimPaymentInformation fields

Field

Description

PatientControlNumber

string

ClaimStatus

string

ClaimChargeAmount

string

ClaimPaymentAmount

string

PatientResponsibilityAmount

string

PayerClaimControlNumber

string

FacilityCode

string

ClaimFrequencyCode

string

ClaimAdjustments

List<ClaimAdjustment> represents the claim adjustments. Use class ClaimAdjustment for reference.

PatientName

EntityProfile represents the patient name. Use class EntityProfile for reference.

InsuredName

EntityProfile represents the insured name. Use class EntityProfile for reference.

CorrectedPatientInsuredName

EntityProfile represents the corrected patient insured name. Use class EntityProfile for reference.

ServiceProviderName

EntityProfile represents the service provider name. Use class EntityProfile for reference.

CrossoverCarrierName

EntityProfile represents the crossover carrier name. Use class EntityProfile for reference.

CorrectedPriorityPayerName

EntityProfile represents the corrected priority payer name. Use class EntityProfile for reference.

OtherSubscriberName

EntityProfile represents the other subscriber name. Use class EntityProfile for reference.

InpatientAdjudicationInformation

InpatientAdjudicationInformation represents the inpatient adjudication information. Use class InpatientAdjudicationInformation for reference.

OutpatientAdjudicationInformation

OutpatientAdjudicationInformation represents the outpatient adjudication information. Use class OutpatientAdjudicationInformation for reference.

OtherClaimRelatedIdentification

List<ReferenceInformation> represents the other claim related identification. Use class ReferenceInformation for reference.

RenderingProviderIdentification

List<ReferenceInformation> represents the rendering provider identification. Use class ReferenceInformation for reference.

ClaimDates

List<DateQualifierValue> represents the claim dates. Use class DateQualifierValue for reference.

CoverageExpirationDate

string

ClaimReceivedDate

string

ClaimSupplementalInformationAmount

List<QualifierAndValue> represents the claim supplemental information amount. Use class QualifierAndValue for reference.

ClaimSupplementalInformationQuantity

List<QualifierAndValue> represents the claim supplemental information quantity. Use class QualifierAndValue for reference.

ServicePaymentInformation

List<ServicePaymentInformation> represents the service payment information. Use class ServicePaymentInformation for reference.

ClaimAdjustment fields

Field

Description

AdjustmentCategory

string

AdjustmentDetails

List<AdjustmentDetails> represents the adjustment details. Use class AdjustmentDetails for reference.

AdjustmentDetails fields

Field

Description

ReferenceIdentification

string

AdjustmentAmount

string

AdjustmentQuantity

string

AdjustmentReason

string

EntityProfile fields

Field

Description

FirstName

string

LastNameOrOrganizationName

string

MiddleName

string

Identifier

string

IdentifierType

string

InpatientAdjudicationInformation fields

Field

Description

CoveredDaysOrVisitCount

string

ProspectivePaymentSystemOperatingOutlierAmount

string

LifetimePsychiatricDaysCount

string

ClaimDiagnosisRelatedGroupAmount

string

ClaimPaymentRemarkCode

string

ClaimDisproportionateShareAmount

string

ClaimMedicareSecondaryPayerPassthroughAmount

string

ClaimProspectivePaymentSystemCapitalAmount

string

ProspectivePaymentSystemCapitalFederalSpecificPortionDiagnosisRelatedGroupAmount

string

ProspectivePaymentSystemCapitalHospitalSpecificPortionDiagnosisRelatedGroupAmount

string

ProspectivePaymentSystemCapitalDisproportionateShareHospitalDiagnosisRelatedGroupAmount

string

OldCapitalAmount

string

ProspectivePaymentSystemCapitalIndirectMedicalEducationAmount

string

ProspectivePaymentSystemOperatingHospitalSpecificDiagnosisRelatedGroupAmount

string

CostReportDayCount

string

ProspectivePaymentSystemFederalSpecificDiagnosisRelatedGroupAmount

string

ClaimProspectivePaymentSystemCapitalOutlierAmount

string

ClaimIndirectTeachingAmount

string

NonpayableProfessionalComponentAmount

string

AdditionalClaimPaymentRemarkCodes

List<string>

ProspectivePaymentSystemCapitalExceptionAmount

string

OutpatientAdjudicationInformation fields

Field

Description

ReimbursementRate

string

ClaimHCPCSPayableAmount

string

ClaimPaymentRemarkCodes

string

ClaimESRDPaymentAmount

string

NonpayableProfessionalComponentAmount

string

DateQualifierValue fields

Field

Description

Date

string

Qualifier

string

QualifierAndValue fields

Field

Description

Value

string

CodeQualifier

string

ServicePaymentInformation fields

Field

Description

MedicalProcedureInformation

MedicalProcedureInformation represents the medical procedure information. Use class MedicalProcedureInformation for reference.

ChargeAmount

string

ProviderPaymentAmount

string

NationalUniformBillingCommitteeRevenueCode

string

QuantityPaid

string

SubmittedMedicalProcedure

MedicalProcedureInformation represents the submitted medical procedure. Use class MedicalProcedureInformation for reference.

QuantitySubmitted

string

ServiceDate

List<DateQualifierValue> represents the service date. Use class DateQualifierValue for reference.

ServiceAdjustment

List<ClaimAdjustment> represents the service adjustment. Use class ClaimAdjustment for reference.

ServiceIdentification

List<ReferenceInformation> represents the service identification. Use class ReferenceInformation for reference.

LineItemControlNumber

ReferenceInformation represents the line item control number. Use class ReferenceInformation for reference.

RenderingProvider

List<ReferenceInformation> represents the rendering provider. Use class ReferenceInformation for reference.

HealthcarePolicyIdentification

List<ReferenceInformation> represents the healthcare policy identification. Use class ReferenceInformation for reference.

ServiceSupplementalAmount

List<QualifierAndValue> represents the service supplemental amount. Use class QualifierAndValue for reference.

ServiceSupplementalQuantity

List<QualifierAndValue> represents the service supplemental quantity. Use class QualifierAndValue for reference.

HealthcareRemarkCodes

List<QualifierAndValue> represents the healthcare remark codes. Use class QualifierAndValue for reference.

MedicalProcedureInformation fields

Field

Description

CodeType

string

ProcedureCode

string

ProcedureCodeModifiers

List<string>

ProviderAdjustment fields

Field

Description

ProviderIdentifier

string

FiscalPeriodDate

string

Adjustments

List<AdjustmentDetails> represents the adjustments. Use class AdjustmentDetails for reference.

Healthcare EDIs

EDI 270 SJ (Patient Eligibility Request)

EDI 271 SJ (Patient Eligibility Request)

EDI 276 (Claim Status Request)

EDI 277 (Claim Status Response)

EDI 834 (Patient Enrollment)

EDI 835 SJ (Claim Payment and Advice)

EDI 837 (Claims)

Acknowledgment EDIs

EDI 997 SJ (Functional Acknowledgment)

EDI 999 SJ (Implementation Acknowledgment)

Freight and Shipping EDIs

EDI 404 (Rail Carrier Shipment Information)

EDI 410 (Rail Carrier Freight Details and Invoice)