What are the most important contents of the 277 and 835 Reports?
Key JSON attributes of any list of multiple payouts in an /835 report include the following:
-
claimPaymentInfo
- multiple instances, each for a different patient claim, all of which are unique in the report. This line defines the beginning of each completed claim within the report. -
payee
- one for each report. This is the provider or institution receiving the payments. -
payer
- one medical insurance payer for each 835 report. Any single Reports file, no matter how many claim records in the transaction list, will have only one Payer. The Payer is unique for each file. -
serviceLines
- the array containing all medical services rendered by the medical provider(s) for the individual patient in each claim. This is arranged just under thepatientName
andrenderingProvider
identifying information. Also watch theserviceDate
attribute instances, which illustrate each individual procedure giving rise to medical service payment requests to the Payer in a claim. Each of these contain the insurance-adjusted payments agreed to by the Payer. Here is a somewhat typicalserviceLines
array record, this one for a dental encounter:
"serviceLines": [
{
"serviceDate": "20190313",
"servicePaymentInformation": {
"productOrServiceIDQualifier": "AD",
"productOrServiceIDQualifierValue": "American Dental Association Codes",
"adjudicatedProcedureCode": "D4342",
"lineItemChargeAmount": "125",
"lineItemProviderPaymentAmount": "0"
},
"serviceAdjustments": [
{
"claimAdjustmentGroupCode": "CO",
"claimAdjustmentGroupCodeValue": "Contractual Obligations",
"adjustmentReasonCode1": "45",
"adjustmentAmount1": "125"
}
]
},
{
"serviceDate": "20190313",
"servicePaymentInformation": {
"productOrServiceIDQualifier": "AD",
"productOrServiceIDQualifierValue": "American Dental Association Codes",
"adjudicatedProcedureCode": "D4381",
"lineItemChargeAmount": "43",
"lineItemProviderPaymentAmount": "0"
},
"serviceAdjustments": [
{
"claimAdjustmentGroupCode": "PR",
"claimAdjustmentGroupCodeValue": "Patient Responsibility",
"adjustmentReasonCode1": "3",
"adjustmentAmount1": "33"
},
{
"claimAdjustmentGroupCode": "CO",
"claimAdjustmentGroupCodeValue": "Contractual Obligations",
"adjustmentReasonCode1": "45",
"adjustmentAmount1": "10"
}
]
},
...
Each line item specifies whether the payer agrees to pay any cash amounts for each line item. Above, the lineItemProviderPaymentAmount
for each indicates the provider did not apply any discounts or on-site payments towards the procedure. Each individual adjudicatedProcedureCode
denotes the procedure line item. The 'serviceAdjustments` object describes the payment the payer agree to pay for each individual line item.
For 277 reports, look for the following:
-
payers
- one for each report. Any single 277 Reports file, no matter how many claim records in the transaction list, will have only one Payer. The Payer is unique for each file. -
You can quickly determine how many claims the current 277 file contains by looking for the following three JSON attributes in a group:
"organizationName": "PREMERA",
"payerIdentification": "430",
"claimStatusTransactions": [
Each of these sets of attributes is the beginning of a complete claim in the transactions
list,
-
claims
- this attribute, which is a bit deeper into each claims record in a list of transactions, describes the completed state of the claim, including thetotalClaimChargeAmount
and theclaimPaymentAmount
along with theremittanceDate
. -
serviceLines
- As with 835s, theserviceLines
objects describe the details of each procedure payment for the individual claims. Added up, the cumulative amounts in theserviceLines
go into thetotalClaimChargeAmount
and theclaimPaymentAmount
along with other totals.
Values in Common
Values such as totalClaimChargeAmount
and the claimPaymentAmount
are common to both types of reports.
Updated about 1 year ago