EDI 837 Health Care Claim

Functional Group HC

X12N Insurance Subcommittee

This Draft Standard for Trial Use contains the format and establishes the data contents of the Health Care Claim Transaction Set (837) for use within the context of an Electronic Data Interchange (EDI) environment. This standard can be used to submit health care claim billing information from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required. For purposes of this standard, providers of health care products or services may include entities such as physicians, hospitals and other medical facilities or suppliers, dentists, and pharmacies. The payer refers to a third party entity that pays claims or administers the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups.

What is an EDI 837?

An EDI 837 Healthcare Claim communicates a patient's healthcare claim, sent from healthcare agencies to insurance providers. It contains information about the patient (SBR segment), the provider (PRV segment), services provided and the cost of the treatment (CLM segment). It must be HIPAA 5010 compliant.

How is an EDI 837 used?

For example, when Person A receives an x-ray, Hospital B will issue an EDI 837 Healthcare Claim to Medical Insurance Provider C. Insurance Provider C will respond to the EDI 837 Healthcare Claim an EDI 835 Health Care Claim Payment/Advice to provide payment or further details.

Heading

Position

Segment

Name

Max use

005Transaction Set HeaderMandatory->Max 1
To indicate the start of a transaction set and to assign a control number
010Beginning SegmentOptional->Max 1
To indicate the beginning of a transaction set.
015Reference NumbersOptional->Max 3
To specify identifying numbers.
1000 Loop Optional
Repeat 10
1. 020Individual or Organizational NameMandatory->Max 1
  To supply the full name of an individual or organizational entity
  Loop 1000 contains submitter and receiver information. If any intermediary receivers change or add data in any way, then they add an occurrence to the loop as a form of identification. The added loop occurrence must be the last occurrence of the loop.
2. 025Additional Name InformationOptional->Max 2
  To specify additional names or those longer than 35 characters in length
3. 030Address InformationOptional->Max 2
  To specify the location of the named party
4. 035Geographic LocationOptional->Max 1
  To specify the geographic place of the named party
5. 040Reference NumbersOptional->Max 2
  To specify identifying numbers.
6. 045Administrative Communications ContactOptional->Max 2
  To identify a person or office to whom administrative communications should be directed

Detail

Position

Segment

Name

Max use

2000 Loop Mandatory
Repeat >1
1. 005Provider InformationMandatory->Max 1
  To specify the identifying characteristics of a provider
  See Figures Appendix for a detail structure of Table 2 of the 837 Transaction Set.
2. 010CurrencyOptional->Max 1
  To specify the currency (dollars, pounds, francs, etc.) used in a transaction
3. 2010 Loop Optional
  Repeat 2
  1. 015Individual or Organizational NameMandatory->Max 1
    To supply the full name of an individual or organizational entity
    Loop 2010 contains provider information: Billing Provider Information, Pay-To Provider
  2. 020Additional Name InformationOptional->Max 2
    To specify additional names or those longer than 35 characters in length
  3. 025Address InformationOptional->Max 2
    To specify the location of the named party
  4. 030Geographic LocationOptional->Max 1
    To specify the geographic place of the named party
  5. 035Reference NumbersOptional->Max 20
    To specify identifying numbers.
  6. 040Administrative Communications ContactOptional->Max 2
    To identify a person or office to whom administrative communications should be directed
4. 2100 Loop Mandatory
  Repeat 99999
  1. 045Subscriber InformationMandatory->Max 1
    To record claim information specific to the primary insured and the insurance carrier for that insured
    Loop 2100 contains information about the subscriber of the current insurance carrier.
  2. 050Date or Time or PeriodOptional->Max 5
    To specify any or all of a date, a time, or a time period
  3. 2110 Loop Optional
    Repeat 10
    055Individual or Organizational NameMandatory->Max 1
    To supply the full name of an individual or organizational entity
    Loop 2110 contains name and address information for: Subscriber, Subscriber's Current Insurance Carrier, Subscriber's School or Employer
    060Additional Name InformationOptional->Max 2
    To specify additional names or those longer than 35 characters in length
    065Address InformationOptional->Max 2
    To specify the location of the named party
    070Geographic LocationOptional->Max 1
    To specify the geographic place of the named party
    075Demographic InformationOptional->Max 1
    To supply demographic information
    080Administrative Communications ContactOptional->Max 2
    To identify a person or office to whom administrative communications should be directed
    085Reference NumbersOptional->Max 5
    To specify identifying numbers.
  4. 2200 Loop Mandatory
    Repeat 99
    090Patient InformationMandatory->Max 1
    To supply patient information
    2210 Loop Optional
    Repeat 10
    095Individual or Organizational NameMandatory->Max 1
    To supply the full name of an individual or organizational entity
    Loop 2210 contains the name and address information for the patient, the patient's legal representative, the party responsible for the patient, and the patient's employer.
    100Additional Name InformationOptional->Max 2
    To specify additional names or those longer than 35 characters in length
    105Address InformationOptional->Max 2
    To specify the location of the named party
    110Geographic LocationOptional->Max 1
    To specify the geographic place of the named party
    115Demographic InformationOptional->Max 1
    To supply demographic information
    120Administrative Communications ContactOptional->Max 2
    To identify a person or office to whom administrative communications should be directed
    125Reference NumbersOptional->Max 5
    To specify identifying numbers.
    2300 Loop Mandatory
    Repeat 100
    130Health ClaimMandatory->Max 1
    To specify basic data about the claim
    135Date or Time or PeriodOptional->Max 40
    To specify any or all of a date, a time, or a time period
    140Claim CodesOptional->Max 1
    To supply information specific to hospital claims
    145Orthodontic InformationOptional->Max 1
    To supply orthodontic information
    150Tooth SummaryOptional->Max 35
    To specify the status of individual teeth
    155PaperworkOptional->Max 10
    To identify the type and transmission of paperwork or supporting information
    160Contract InformationOptional->Max 1
    To specify basic data about the contract
    165Disability InformationOptional->Max 1
    To supply disability information
    170Peer Review Organization or Utilization ReviewOptional->Max 1
    To specify the results of the utilization review
    175Monetary AmountOptional->Max 40
    To indicate the total monetary amount.
    180Reference NumbersOptional->Max 30
    To specify identifying numbers.
    185File InformationOptional->Max 10
    To transmit a fixed format record
    190Note/Special InstructionOptional->Max 4
    To transmit information in a free-form format, if necessary, for comment or special instruction
    195Ambulance CertificationOptional->Max 1
    To supply information related to the ambulance service rendered to a patient
    The CR1 through CR5 and CRC certification segments appear on both the claim level and the service line level because certifications can be submitted for all services on a claim or for individual services. Certification information at the claim level applies to all service lines of the claim, unless overridden by certification information at the service line level.
    200Chiropractic CertificationOptional->Max 1
    To supply information related to the chiropractic service rendered to a patient
    205Durable Medical Equipment CertificationOptional->Max 1
    To supply information regarding a physician's certification for durable medical equipment
    210Enteral or Parenteral Therapy CertificationOptional->Max 3
    To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy
    215Oxygen Therapy CertificationOptional->Max 1
    To supply information regarding certification of medical necessity for home oxygen therapy
    218Pacemaker CertificationOptional->Max 1
    To supply information related to Pacemaker registry.
    220Conditions IndicatorOptional->Max 3
    To supply information on conditions
    225Medical Procedures CodeOptional->Max 25
    To specify medical procedures codes and the dates associated with them
    230Informational ValuesOptional->Max 25
    To specify a code and the amount, quantity associated with it, or both
    235Multi-Valued CharacteristicsOptional->Max 30
    To provide characteristics that may have multiple values
    240QuantityOptional->Max 10
    To specify quantity information.
    241Health Care PricingOptional->Max 1
    To specify pricing or repricing information about a health care claim or line item
    245Loop HeaderOptional->Max 1
    To indicate that the next segment begins a loop
    2310 Loop Optional
    Repeat 9
    250Individual or Organizational NameMandatory->Max 1
    To supply the full name of an individual or organizational entity
    Loop 2310 contains information about the rendering, referring, or attending provider.
    255Provider InformationOptional->Max 1
    To specify the identifying characteristics of a provider
    260Additional Name InformationOptional->Max 2
    To specify additional names or those longer than 35 characters in length
    265Address InformationOptional->Max 2
    To specify the location of the named party
    270Geographic LocationOptional->Max 1
    To specify the geographic place of the named party
    275Administrative Communications ContactOptional->Max 2
    To identify a person or office to whom administrative communications should be directed
    280Loop TrailerOptional->Max 1
    To indicate that the loop immediately preceding this segment is complete
    2400 Loop Optional
    Repeat 10000
    285Assigned NumberMandatory->Max 1
    To reference a line number in a transaction set.
    Loop 2400 contains Service Line information.
    290Professional ServiceOptional->Max 1
    To specify the claim service detail for a Health Care professional
    295Institutional ServiceOptional->Max 1
    To specify the claim service detail for a Health Care institution
    300Dental ServiceOptional->Max 1
    To specify the claim service detail for dental work
    305Drug ServiceOptional->Max 1
    To specify the claim service detail for prescription drugs
    2410 Loop Optional
    Repeat 10
    310Item IdentificationMandatory->Max 1
    To specify basic item identification data.
    Loop 2410 contains compound drug components, quantities and prices.
    315Pricing InformationOptional->Max 1
    To specify pricing information
    320Durable Medical Equipment ServiceOptional->Max 1
    To specify the claim service detail for durable medical equipment
    325Anesthesia ServiceOptional->Max 1
    To specify the claim service detail for anesthesia
    330Drug AdjudicationOptional->Max 1
    To specify the claim service detail for drug services that have been adjudicated
    335Multi-Valued CharacteristicsOptional->Max 5
    To provide characteristics that may have multiple values
    340PaperworkOptional->Max 10
    To identify the type and transmission of paperwork or supporting information
    345Ambulance CertificationOptional->Max 1
    To supply information related to the ambulance service rendered to a patient
    The CR1 through CR5 and CRC certification segments appear on both the claim level and the service line level because certifications can be submitted for all services on a claim or for individual services. Certification information at the claim level applies to all service lines of the claim, unless overridden by certification information at the service line level.
    350Chiropractic CertificationOptional->Max 5
    To supply information related to the chiropractic service rendered to a patient
    355Durable Medical Equipment CertificationOptional->Max 1
    To supply information regarding a physician's certification for durable medical equipment
    360Enteral or Parenteral Therapy CertificationOptional->Max 3
    To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy
    365Oxygen Therapy CertificationOptional->Max 1
    To supply information regarding certification of medical necessity for home oxygen therapy
    370Conditions IndicatorOptional->Max 3
    To supply information on conditions
    375Date or Time or PeriodOptional->Max 15
    To specify any or all of a date, a time, or a time period
    380QuantityOptional->Max 5
    To specify quantity information.
    385Contract InformationOptional->Max 1
    To specify basic data about the contract
    390Reference NumbersOptional->Max 30
    To specify identifying numbers.
    395Monetary AmountOptional->Max 15
    To indicate the total monetary amount.
    400File InformationOptional->Max 10
    To transmit a fixed format record
    405Note/Special InstructionOptional->Max 10
    To transmit information in a free-form format, if necessary, for comment or special instruction
    410Purchase ServiceOptional->Max 1
    To specify the information about services that are purchased
    411Health Care PricingOptional->Max 1
    To specify pricing or repricing information about a health care claim or line item
    415Loop HeaderOptional->Max 1
    To indicate that the next segment begins a loop
    2420 Loop Optional
    Repeat 10
    420Individual or Organizational NameMandatory->Max 1
    To supply the full name of an individual or organizational entity
    Loop 2420 contains information about the rendering, referring, or attending provider on a service line level. These segments override the information in the claim - level segments if the entity identifier codes in each NM1 segment are the same.
    425Provider InformationOptional->Max 1
    To specify the identifying characteristics of a provider
    430Additional Name InformationOptional->Max 2
    To specify additional names or those longer than 35 characters in length
    435Address InformationOptional->Max 2
    To specify the location of the named party
    440Geographic LocationOptional->Max 1
    To specify the geographic place of the named party
    445Administrative Communications ContactOptional->Max 2
    To identify a person or office to whom administrative communications should be directed
    450Loop TrailerOptional->Max 1
    To indicate that the loop immediately preceding this segment is complete
    455Loop HeaderOptional->Max 1
    To indicate that the next segment begins a loop
    2500 Loop Optional
    Repeat 10
    460Subscriber InformationMandatory->Max 1
    To record claim information specific to the primary insured and the insurance carrier for that insured
    Loop 2500 contains insurance information about: Paying and Other Insurance Carriers for that Subscriber, Subscriber of the Other Insurance Carriers, School or Employer Information for that Subscriber
    Segments NM1 - N4 contain name and address information of the insurance carriers referenced in the above note.
    465Claim AdjudicationOptional->Max 1
    To specify the adjudication codes for a claim service item
    470Monetary AmountOptional->Max 15
    To indicate the total monetary amount.
    475Demographic InformationOptional->Max 1
    To supply demographic information
    480Other Health Insurance InformationOptional->Max 1
    To specify information associated with other health insurance coverage
    2510 Loop Optional
    Repeat 10
    485Individual or Organizational NameMandatory->Max 1
    To supply the full name of an individual or organizational entity
    490Additional Name InformationOptional->Max 2
    To specify additional names or those longer than 35 characters in length
    495Address InformationOptional->Max 2
    To specify the location of the named party
    500Geographic LocationOptional->Max 1
    To specify the geographic place of the named party
    505Administrative Communications ContactOptional->Max 2
    To identify a person or office to whom administrative communications should be directed
    510Date or Time or PeriodOptional->Max 2
    To specify any or all of a date, a time, or a time period
    515Reference NumbersOptional->Max 3
    To specify identifying numbers.
    520Loop TrailerOptional->Max 1
    To indicate that the loop immediately preceding this segment is complete
525Transaction Set TrailerMandatory->Max 1
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments).

Figures Appendix

Following is a figure detailing the overall structure of Table 2 of the 837 Transaction Set.

2000     PROVIDER (Billing Provider)
2100           SUBSCRIBER
2200                 PATIENT
2300                       CLAIM
2400                             SERVICE LINE(S)
2500                             INSURANCE
2300                       CLAIM
2400                             SERVICE LINE(S)
2200                 PATIENT
2300                       CLAIM
2400                             SERVICE LINE(S)
2500                             INSURANCE
2100           SUBSCRIBER
2200                 PATIENT
2300                       CLAIM
2300                       CLAIM
2000     PROVIDER (Billing Provider)
2100           SUBSCRIBER
2200                 PATIENT
2300                       CLAIM
2400                             SERVICE LINE(S)
2500                             INSURANCE
2100           SUBSCRIBER
2200                 PATIENT
2300                       CLAIM