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 or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment. 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, and entities providing medical information to meet regulatory requirements. 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. A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific health care/insurance industry segment.

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 of Hierarchical TransactionMandatory->Max 1
To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time
015Reference IdentificationOptional->Max 3
To specify identifying information
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 IdentificationOptional->Max 2
  To specify identifying information
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. 001Hierarchical LevelMandatory->Max 1
  To identify dependencies among and the content of hierarchically related groups of data segments
2. 003Provider InformationOptional->Max 1
  To specify the identifying characteristics of a provider
3. 005Subscriber InformationOptional->Max 1
  To record information specific to the primary insured and the insurance carrier for that insured
4. 007Patient InformationOptional->Max 1
  To supply patient information
5. 009Date or Time or PeriodOptional->Max 5
  To specify any or all of a date, a time, or a time period
6. 010CurrencyOptional->Max 1
  To specify the currency (dollars, pounds, francs, etc.) used in a transaction
7. 2010 Loop Optional
  Repeat 10
  1. 015Individual or Organizational NameMandatory->Max 1
    To supply the full name of an individual or organizational entity
    Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these entities may include billing provider, pay-to provider, insurer, primary administrator, contract holder, or claimant.
  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. 032Demographic InformationOptional->Max 1
    To supply demographic information
  6. 035Reference IdentificationOptional->Max 20
    To specify identifying information
  7. 040Administrative Communications ContactOptional->Max 2
    To identify a person or office to whom administrative communications should be directed
8. 2300 Loop Optional
  Repeat 100
  1. 130Health ClaimMandatory->Max 1
    To specify basic data about the claim
  2. 135Date or Time or PeriodOptional->Max 150
    To specify any or all of a date, a time, or a time period
  3. 140Claim CodesOptional->Max 1
    To supply information specific to hospital claims
  4. 145Orthodontic InformationOptional->Max 1
    To supply orthodontic information
  5. 150Tooth SummaryOptional->Max 35
    To specify the status of individual teeth
  6. 155PaperworkOptional->Max 10
    To identify the type and transmission of paperwork or supporting information
  7. 160Contract InformationOptional->Max 1
    To specify basic data about the contract or contract line item
  8. 165Disability InformationOptional->Max 1
    To supply disability information
  9. 170Peer Review Organization or Utilization ReviewOptional->Max 1
    To specify the results of the utilization review
  10. 175Monetary AmountOptional->Max 40
    To indicate the total monetary amount
  11. 180Reference IdentificationOptional->Max 30
    To specify identifying information
  12. 185File InformationOptional->Max 10
    To transmit a fixed-format record or matrix contents
  13. 190Note/Special InstructionOptional->Max 20
    To transmit information in a free-form format, if necessary, for comment or special instruction
  14. 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.
  15. 200Chiropractic CertificationOptional->Max 1
    To supply information related to the chiropractic service rendered to a patient
  16. 205Durable Medical Equipment CertificationOptional->Max 1
    To supply information regarding a physician's certification for durable medical equipment
  17. 210Enteral or Parenteral Therapy CertificationOptional->Max 3
    To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy
  18. 215Oxygen Therapy CertificationOptional->Max 1
    To supply information regarding certification of medical necessity for home oxygen therapy
  19. 216Home Health Care CertificationOptional->Max 1
    To supply information related to the certification of a home health care patient
  20. 219Pacemaker CertificationOptional->Max 1
    To supply information related to Pacemaker registry
  21. 220Conditions IndicatorOptional->Max 100
    To supply information on conditions
  22. 231Health Care Information CodesOptional->Max 25
    To supply information related to the delivery of health care
  23. 240QuantityOptional->Max 10
    To specify quantity information
  24. 241Health Care PricingOptional->Max 1
    To specify pricing or repricing information about a health care claim or line item
  25. 2305 Loop Optional
    Repeat 6
    242Home Health Treatment Plan CertificationMandatory->Max 1
    To supply information related to the home health care plan of treatment and services
    243Health Care Services DeliveryOptional->Max 12
    To specify the delivery pattern of health care services
  26. 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
    271Reference IdentificationOptional->Max 20
    To specify identifying information
    275Administrative Communications ContactOptional->Max 2
    To identify a person or office to whom administrative communications should be directed
  27. 2320 Loop Optional
    Repeat 10
    290Subscriber InformationMandatory->Max 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 AdjustmentOptional->Max 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 AmountOptional->Max 15
    To indicate the total monetary amount
    305Demographic InformationOptional->Max 1
    To supply demographic information
    310Other Health Insurance InformationOptional->Max 1
    To specify information associated with other health insurance coverage
    315Medicare Inpatient AdjudicationOptional->Max 1
    To provide claim-level data related to the adjudication of Medicare inpatient claims
    320Medicare Outpatient AdjudicationOptional->Max 1
    To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting
    2330 Loop Optional
    Repeat 10
    325Individual or Organizational NameMandatory->Max 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 InformationOptional->Max 2
    To specify additional names or those longer than 35 characters in length
    332Address InformationOptional->Max 2
    To specify the location of the named party
    340Geographic LocationOptional->Max 1
    To specify the geographic place of the named party
    345Administrative Communications ContactOptional->Max 2
    To identify a person or office to whom administrative communications should be directed
    350Date or Time or PeriodOptional->Max 9
    To specify any or all of a date, a time, or a time period
    355Reference IdentificationOptional->Max 3
    To specify identifying information
  28. 2400 Loop Optional
    Repeat >1
    365Assigned NumberMandatory->Max 1
    To reference a line number in a transaction set
    Loop 2400 contains Service Line information.
    370Professional ServiceOptional->Max 1
    To specify the claim service detail for a Health Care professional
    375Institutional ServiceOptional->Max 1
    To specify the claim service detail for a Health Care institution
    380Dental ServiceOptional->Max 1
    To specify the claim service detail for dental work
    382Tooth IdentificationOptional->Max 32
    To identify a tooth by number and, if applicable, one or more tooth surfaces
    385Drug ServiceOptional->Max 1
    To specify the claim service detail for prescription drugs
    400Durable Medical Equipment ServiceOptional->Max 1
    To specify the claim service detail for durable medical equipment
    405Anesthesia ServiceOptional->Max 1
    To specify the claim service detail for anesthesia
    410Drug AdjudicationOptional->Max 1
    To specify the claim service detail for drug services that have been adjudicated
    415Health Care Information CodesOptional->Max 25
    To supply information related to the delivery of health care
    420PaperworkOptional->Max 10
    To identify the type and transmission of paperwork or supporting information
    425Ambulance 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.
    430Chiropractic CertificationOptional->Max 5
    To supply information related to the chiropractic service rendered to a patient
    435Durable Medical Equipment CertificationOptional->Max 1
    To supply information regarding a physician's certification for durable medical equipment
    440Enteral or Parenteral Therapy CertificationOptional->Max 3
    To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy
    445Oxygen Therapy CertificationOptional->Max 1
    To supply information regarding certification of medical necessity for home oxygen therapy
    450Conditions IndicatorOptional->Max 3
    To supply information on conditions
    455Date or Time or PeriodOptional->Max 15
    To specify any or all of a date, a time, or a time period
    460QuantityOptional->Max 5
    To specify quantity information
    462MeasurementsOptional->Max 20
    To specify physical measurements or counts, including dimensions, tolerances, variances, and weights (See Figures Appendix for example of use of C001)
    465Contract InformationOptional->Max 1
    To specify basic data about the contract or contract line item
    470Reference IdentificationOptional->Max 30
    To specify identifying information
    475Monetary AmountOptional->Max 15
    To indicate the total monetary amount
    480File InformationOptional->Max 10
    To transmit a fixed-format record or matrix contents
    485Note/Special InstructionOptional->Max 10
    To transmit information in a free-form format, if necessary, for comment or special instruction
    490Purchase ServiceOptional->Max 1
    To specify the information about services that are purchased
    492Health Care PricingOptional->Max 1
    To specify pricing or repricing information about a health care claim or line item
    2410 Loop Optional
    Repeat 10
    493Item IdentificationMandatory->Max 1
    To specify basic item identification data
    Loop 2410 contains compound drug components, quantities and prices.
    494Pricing InformationOptional->Max 1
    To specify pricing information
    2420 Loop Optional
    Repeat 10
    500Individual 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.
    505Provider InformationOptional->Max 1
    To specify the identifying characteristics of a provider
    510Additional Name InformationOptional->Max 2
    To specify additional names or those longer than 35 characters in length
    514Address InformationOptional->Max 2
    To specify the location of the named party
    520Geographic LocationOptional->Max 1
    To specify the geographic place of the named party
    525Reference IdentificationOptional->Max 20
    To specify identifying information
    530Administrative Communications ContactOptional->Max 2
    To identify a person or office to whom administrative communications should be directed
    2430 Loop Optional
    Repeat >1
    540Service Line AdjudicationMandatory->Max 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 AdjustmentOptional->Max 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 PeriodOptional->Max 9
    To specify any or all of a date, a time, or a time period
555Transaction 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