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 the patientName and renderingProvider identifying information. Also watch the serviceDate 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 typical serviceLines 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 the totalClaimChargeAmount and the claimPaymentAmount along with the remittanceDate.

• serviceLines - As with 835s, the serviceLines objects describe the details of each procedure payment for the individual claims. Added up, the cumulative amounts in the serviceLines go into the totalClaimChargeAmount and the claimPaymentAmount along with other totals.

Values in Common

Values such as totalClaimChargeAmount and the claimPaymentAmount are common to both types of reports.