Medical Professional Claims: 837 vs 835

The 837 file is a form used by HCP/HCO to communicate healthcare claims. The file itself may contain multiple claims, and includes…

The 837 file is a form used by HCP/HCO to communicate healthcare claims. The file itself may contain multiple claims, and includes information that details aspects of patients’ treatment, e.g. medical services provided, cost of treatment, adjustments, and actual claim amount.

The 835 file, a.k.a Electronic Remittance Advice (ERA), is an electronic transaction that provides claim payment information and documents the transfer of fund. The file is sent from insurers to providers that provide notice and explanation of reasons for payment, adjustment, denial, and/or uncovered chargers of a medical claim.

In terms of information included in the form, there are some overlaps with 837s; however, they have significant differences. For example, remits do not include diagnosis codes, or there is not a one-to-one mapping between 837 and 835, and sometimes multiple 835 forms for one 837 claim. Additionally, 835 includes information about the services being paid for (either in full or a reduced amount). Also, it also includes insurance information about deductibles, co-pay amounts, splitting of healthcare claims, co-insurers, and bundling. Basically if we assume an 837 is a bill, then 835 is the receipt of that bill. Providers send the bill to insurers and then sometime later, insurers provider transfer a fund to the providers bank account and send a record of that transaction as part of the 835 file.