Member Claim Level File

InstaMed supports the ability to send payments (and denials) to members (Explanation of Benefits or EOB). These outbound payments consist of claims adjudicated by a health plan and owed to a member.

In order to properly reflect the disposition of an adjudicated claim, issued via the InstaMed Disbursement Hub solution, InstaMed supports the generation of claim-level batch files.

For example, if a check payment, consisting of 5 claims, was issued for $1,000, each of these claims would be reported as an individual row in the batch file with a ‘Paid’ status. InstaMed will output another batch file in the future when the check is deposited to change the status of each of the claims from ‘Paid’ to ‘Settled’.

The specification below is used to report on the status of specific claims issued by InstaMed as part of a payment/835 transaction.

Files are output in a pipe delimited format and uploaded to client-specific SFTP directories.

Field #Field NameFormatMinMaxRequiredComment
1Record ID"IMCRE10"77Y
2ClaimIDAN118SInternal Claim ID REF*9A field
6ClaimPaymentDECSCLP04 - Available when transaction status is Fulfilled
7PaymentDateAN88SYYYYMMDD, Available when transaction status is Fulfilled
8DisbursmentTraceNumberAN130STRN02 - Disbursed check/trace number to provider; Available when transaction status is Fulfilled
9DisbursmentEntityAN1042STRN03:TRN04 - Available when transaction status is Fulfilled
10FundingTraceNumberAN130SFrom original file -- TRN02
11FundingEntityAN1042SFrom original file -- TRN03:TRN04
12Payer NameAN135YN102 when N101 = PR
13Payee LastAN135YN102 when N101 = PE
14Payee FirstAN135S
15Payee Primary ID QualifierAN22YN103 when N101 = PE
16Payee Primary IDAN180YN104 when N101 = PE
17Patient Last NameAN135YNM103 when NM101 = QC
18Patient First NameAN135YNM104 when NM101 = QC
19Patient Middle NameAN125SNM105 when NM101 = QC
20Patient ID QualifierAN22YNM108 when NM101 = QC
21Patient IDAN180YNM109 when NM101 = QC
22StatusAN120YFULFILLED: Disbursed payments
SUSPENDED: Suspended payments
SETTLED: Settled payments
PENDING APPROVAL: Payments that are available for approval in InstaMed Online
VOIDED: Payments were voided by client via their bank
RETURNED: Returned payments
STOPPED: Payments were stopped by client via their bank
REMOVED: Payments was removed from Pending Approval
Date that print vendor placed item into mailstream; Always populated for CHK
25Placeholder Field 2ANReserved for future use
26Placeholder Field 3ANReserved for future use
27Placeholder Field 4ANReserved for future use
28Placeholder Field 5ANReserved for future use
29Placeholder Field 6ANReserved for future use
30Placeholder Field 7ANReserved for future use
31Placeholder Field 8ANReserved for future use
32Placeholder Field 9ANReserved for future use
33Placeholder Field 10ANReserved for future use
34Placeholder Field 11DECReserved for future use
35Placeholder Field 12DECReserved for future use
36Placeholder Field 13DECReserved for future use
37Placeholder Field 14DECReserved for future use
38Placeholder Field 15DECReserved for future use