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 transaction set can be used to submit health care claim billing information, encounter information, or both, 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
- 005Transaction Set HeaderMandatoryMax 1
To indicate the start of a transaction set and to assign a control number
- 010Beginning SegmentOptionalMax 1
To indicate the beginning of a transaction set.
- 015Reference NumbersOptionalMax 3
To specify identifying numbers.
- 1000 Loop OptionalRepeat 10
- 020Individual or Organizational NameMandatoryMax 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. - 025Additional Name InformationOptionalMax 2
To specify additional names or those longer than 35 characters in length
- 030Address InformationOptionalMax 2
To specify the location of the named party
- 035Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 040Reference NumbersOptionalMax 2
To specify identifying numbers.
- 045Administrative Communications ContactOptionalMax 2
To identify a person or office to whom administrative communications should be directed
- 020Individual or Organizational NameMandatoryMax 1
Detail
- 2000 Loop MandatoryRepeat >1
- 005Provider InformationMandatoryMax 1
To specify the identifying characteristics of a provider
See Figures Appendix for a detail structure of Table 2 of the 837 Transaction Set. - 010CurrencyOptionalMax 1
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
- 2010 Loop OptionalRepeat 2
- 015Individual or Organizational NameMandatoryMax 1
To supply the full name of an individual or organizational entity
Loop 2010 contains provider information: Billing Provider Information, Pay-To Provider - 020Additional Name InformationOptionalMax 2
To specify additional names or those longer than 35 characters in length
- 025Address InformationOptionalMax 2
To specify the location of the named party
- 030Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 035Reference NumbersOptionalMax 20
To specify identifying numbers.
- 040Administrative Communications ContactOptionalMax 2
To identify a person or office to whom administrative communications should be directed
- 015Individual or Organizational NameMandatoryMax 1
- 2100 Loop MandatoryRepeat >1
- 045Subscriber InformationMandatoryMax 1
To record 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. - 050Date or Time or PeriodOptionalMax 5
To specify any or all of a date, a time, or a time period
- 2110 Loop OptionalRepeat 10
- 055Individual or Organizational NameMandatoryMax 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 InformationOptionalMax 2
To specify additional names or those longer than 35 characters in length
- 065Address InformationOptionalMax 2
To specify the location of the named party
- 070Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 075Demographic InformationOptionalMax 1
To supply demographic information
- 080Administrative Communications ContactOptionalMax 2
To identify a person or office to whom administrative communications should be directed
- 085Reference NumbersOptionalMax 5
To specify identifying numbers.
- 055Individual or Organizational NameMandatoryMax 1
- 2200 Loop MandatoryRepeat 99
- 090Patient InformationMandatoryMax 1
To supply patient information
- 2210 Loop OptionalRepeat 10
- 095Individual or Organizational NameMandatoryMax 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 InformationOptionalMax 2
To specify additional names or those longer than 35 characters in length
- 105Address InformationOptionalMax 2
To specify the location of the named party
- 110Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 115Demographic InformationOptionalMax 1
To supply demographic information
- 120Administrative Communications ContactOptionalMax 2
To identify a person or office to whom administrative communications should be directed
- 125Reference NumbersOptionalMax 5
To specify identifying numbers.
- 095Individual or Organizational NameMandatoryMax 1
- 2300 Loop MandatoryRepeat 100
- 130Health ClaimMandatoryMax 1
To specify basic data about the claim
- 135Date or Time or PeriodOptionalMax 150
To specify any or all of a date, a time, or a time period
- 140Claim CodesOptionalMax 1
To supply information specific to hospital claims
- 145Orthodontic InformationOptionalMax 1
To supply orthodontic information
- 150Tooth SummaryOptionalMax 35
To specify the status of individual teeth
- 155PaperworkOptionalMax 10
To identify the type and transmission of paperwork or supporting information
- 160Contract InformationOptionalMax 1
To specify basic data about the contract or contract line item
- 165Disability InformationOptionalMax 1
To supply disability information
- 170Peer Review Organization or Utilization ReviewOptionalMax 1
To specify the results of the utilization review
- 175Monetary AmountOptionalMax 40
To indicate the total monetary amount.
- 180Reference NumbersOptionalMax 30
To specify identifying numbers.
- 185File InformationOptionalMax 10
To transmit a fixed format record
- 190Note/Special InstructionOptionalMax 20
To transmit information in a free-form format, if necessary, for comment or special instruction
- 195Ambulance CertificationOptionalMax 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 CertificationOptionalMax 1
To supply information related to the chiropractic service rendered to a patient
- 205Durable Medical Equipment CertificationOptionalMax 1
To supply information regarding a physician's certification for durable medical equipment
- 210Enteral or Parenteral Therapy CertificationOptionalMax 3
To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy
- 215Oxygen Therapy CertificationOptionalMax 1
To supply information regarding certification of medical necessity for home oxygen therapy
- 216Home Health Care CertificationOptionalMax 1
To supply information related to the certification of a home health care patient
- 219Pacemaker CertificationOptionalMax 1
To supply information related to Pacemaker registry.
- 220Conditions IndicatorOptionalMax 100
To supply information on conditions
- 231Health Care Information CodesOptionalMax 25
To supply information related to the delivery of health care
- 240QuantityOptionalMax 10
To specify quantity information.
- 241Health Care PricingOptionalMax 1
To specify pricing or repricing information about a health care claim or line item
- 2305 Loop OptionalRepeat 6
- 242Home Health Treatment Plan CertificationMandatoryMax 1
To supply information related to the home health care plan of treatment and services
- 243Health Care Services DeliveryOptionalMax 12
To specify the delivery pattern of health care services
- 242Home Health Treatment Plan CertificationMandatoryMax 1
- 245Loop HeaderOptionalMax 1
To indicate that the next segment begins a loop
- 2310 Loop OptionalRepeat 9
- 250Individual or Organizational NameMandatoryMax 1
To supply the full name of an individual or organizational entity
Loop 2310 contains information about the rendering, referring, or attending provider. - 255Provider InformationOptionalMax 1
To specify the identifying characteristics of a provider
- 260Additional Name InformationOptionalMax 2
To specify additional names or those longer than 35 characters in length
- 265Address InformationOptionalMax 2
To specify the location of the named party
- 270Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 271Reference NumbersOptionalMax 20
To specify identifying numbers.
- 275Administrative Communications ContactOptionalMax 2
To identify a person or office to whom administrative communications should be directed
- 250Individual or Organizational NameMandatoryMax 1
- 280Loop TrailerOptionalMax 1
To indicate that the loop immediately preceding this segment is complete
- 285Loop HeaderOptionalMax 1
To indicate that the next segment begins a loop
- 2320 Loop OptionalRepeat 10
- 290Subscriber InformationMandatoryMax 1
To record information specific to the primary insured and the insurance carrier for that insured
Loop 2320 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. - 295Claims AdjustmentOptionalMax 1
To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid
- 300Monetary AmountOptionalMax 15
To indicate the total monetary amount.
- 305Demographic InformationOptionalMax 1
To supply demographic information
- 310Other Health Insurance InformationOptionalMax 1
To specify information associated with other health insurance coverage
- 315Medicare Inpatient AdjudicationOptionalMax 1
To provide claim-level data related to the adjudication of Medicare inpatient claims
- 320Medicare Outpatient AdjudicationOptionalMax 1
To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting
- 2330 Loop OptionalRepeat 10
- 325Individual or Organizational NameMandatoryMax 1
To supply the full name of an individual or organizational entity
Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320. - 330Additional Name InformationOptionalMax 2
To specify additional names or those longer than 35 characters in length
- 332Address InformationOptionalMax 2
To specify the location of the named party
- 340Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 345Administrative Communications ContactOptionalMax 2
To identify a person or office to whom administrative communications should be directed
- 350Date or Time or PeriodOptionalMax 9
To specify any or all of a date, a time, or a time period
- 355Reference NumbersOptionalMax 3
To specify identifying numbers.
- 325Individual or Organizational NameMandatoryMax 1
- 290Subscriber InformationMandatoryMax 1
- 360Loop TrailerOptionalMax 1
To indicate that the loop immediately preceding this segment is complete
- 2400 Loop OptionalRepeat >1
- 365Assigned NumberMandatoryMax 1
To reference a line number in a transaction set.
Loop 2400 contains Service Line information. - 370Professional ServiceOptionalMax 1
To specify the claim service detail for a Health Care professional
- 375Institutional ServiceOptionalMax 1
To specify the claim service detail for a Health Care institution
- 380Dental ServiceOptionalMax 1
To specify the claim service detail for dental work
- 382Tooth IdentificationOptionalMax 32
To identify a tooth by number and, if applicable, one or more tooth surfaces
- 385Drug ServiceOptionalMax 1
To specify the claim service detail for prescription drugs
- 400Durable Medical Equipment ServiceOptionalMax 1
To specify the claim service detail for durable medical equipment
- 405Anesthesia ServiceOptionalMax 1
To specify the claim service detail for anesthesia
- 410Drug AdjudicationOptionalMax 1
To specify the claim service detail for drug services that have been adjudicated
- 415Health Care Information CodesOptionalMax 25
To supply information related to the delivery of health care
- 420PaperworkOptionalMax 10
To identify the type and transmission of paperwork or supporting information
- 425Ambulance CertificationOptionalMax 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. - 430Chiropractic CertificationOptionalMax 5
To supply information related to the chiropractic service rendered to a patient
- 435Durable Medical Equipment CertificationOptionalMax 1
To supply information regarding a physician's certification for durable medical equipment
- 440Enteral or Parenteral Therapy CertificationOptionalMax 3
To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy
- 441Reference NumbersOptionalMax 20
To specify identifying numbers.
- 445Oxygen Therapy CertificationOptionalMax 1
To supply information regarding certification of medical necessity for home oxygen therapy
- 450Conditions IndicatorOptionalMax 3
To supply information on conditions
- 455Date or Time or PeriodOptionalMax 15
To specify any or all of a date, a time, or a time period
- 460QuantityOptionalMax 5
To specify quantity information.
- 465Contract InformationOptionalMax 1
To specify basic data about the contract or contract line item
- 470Reference NumbersOptionalMax 30
To specify identifying numbers.
- 475Monetary AmountOptionalMax 15
To indicate the total monetary amount.
- 480File InformationOptionalMax 10
To transmit a fixed format record
- 485Note/Special InstructionOptionalMax 10
To transmit information in a free-form format, if necessary, for comment or special instruction
- 490Purchase ServiceOptionalMax 1
To specify the information about services that are purchased
- 492Health Care PricingOptionalMax 1
To specify pricing or repricing information about a health care claim or line item
- 2410 Loop OptionalRepeat 10
- 493Item IdentificationMandatoryMax 1
To specify basic item identification data.
Loop 2410 contains compound drug components, quantities and prices. - 494Pricing InformationOptionalMax 1
To specify pricing information
- 493Item IdentificationMandatoryMax 1
- 495Loop HeaderOptionalMax 1
To indicate that the next segment begins a loop
- 2420 Loop OptionalRepeat 10
- 500Individual or Organizational NameMandatoryMax 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. - 505Provider InformationOptionalMax 1
To specify the identifying characteristics of a provider
- 510Additional Name InformationOptionalMax 2
To specify additional names or those longer than 35 characters in length
- 514Address InformationOptionalMax 2
To specify the location of the named party
- 520Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 525Reference NumbersOptionalMax 20
To specify identifying numbers.
- 530Administrative Communications ContactOptionalMax 2
To identify a person or office to whom administrative communications should be directed
- 500Individual or Organizational NameMandatoryMax 1
- 535Loop TrailerOptionalMax 1
To indicate that the loop immediately preceding this segment is complete
- 2430 Loop OptionalRepeat >1
- 540Service Line AdjudicationMandatoryMax 1
To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers
SVD01 identifies the payer which adjudicated the corresponding service line and must match DE 67 in the NM109 position 325 for the payer. - 545Claims AdjustmentOptionalMax 99
To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid
- 550Date or Time or PeriodOptionalMax 9
To specify any or all of a date, a time, or a time period
- 540Service Line AdjudicationMandatoryMax 1
- 365Assigned NumberMandatoryMax 1
- 130Health ClaimMandatoryMax 1
- 090Patient InformationMandatoryMax 1
- 045Subscriber InformationMandatoryMax 1
- 005Provider InformationMandatoryMax 1
- 555Transaction Set TrailerMandatoryMax 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