EDI 837 Health Care Claim

Functional Group HC

X12N Insurance Subcommittee

This X12 Transaction Set 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

0050Transaction Set HeaderMandatory->Max 1
To indicate the start of a transaction set and to assign a control number
0100Beginning 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
0150Reference InformationOptional->Max 3
To specify identifying information
1000 Loop Optional
Repeat 10
1. 0200Individual 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. 0250Additional Name InformationOptional->Max 2
  To specify additional names
3. 0300Party LocationOptional->Max 2
  To specify the location of the named party
4. 0350Geographic LocationOptional->Max 1
  To specify the geographic place of the named party
5. 0400Reference InformationOptional->Max 2
  To specify identifying information
6. 0450Administrative 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. 0010Hierarchical LevelMandatory->Max 1
  To identify dependencies among and the content of hierarchically related groups of data segments
2. 0030Provider InformationOptional->Max 1
  To specify the identifying characteristics of a provider
3. 0050Subscriber InformationOptional->Max 1
  To record information specific to the primary insured and the insurance carrier for that insured
4. 0070Patient InformationOptional->Max 1
  To supply patient information
5. 0090Date or Time or PeriodOptional->Max 5
  To specify any or all of a date, a time, or a time period
6. 0100CurrencyOptional->Max 1
  To specify the currency (dollars, pounds, francs, etc.) used in a transaction
7. 2010 Loop Optional
  Repeat 10
  1. 0150Individual 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. 0200Additional Name InformationOptional->Max 2
    To specify additional names
  3. 0250Party LocationOptional->Max 2
    To specify the location of the named party
  4. 0300Geographic LocationOptional->Max 1
    To specify the geographic place of the named party
  5. 0320Demographic InformationOptional->Max 1
    To supply demographic information
  6. 0350Reference InformationOptional->Max 20
    To specify identifying information
  7. 0400Administrative Communications ContactOptional->Max 2
    To identify a person or office to whom administrative communications should be directed
8. 2300 Loop Optional
  Repeat 100
  1. 1300Health ClaimMandatory->Max 1
    To specify basic data about the claim
  2. 1350Date or Time or PeriodOptional->Max 150
    To specify any or all of a date, a time, or a time period
  3. 1400Claim CodesOptional->Max 1
    To supply information specific to hospital claims
  4. 1450Orthodontic InformationOptional->Max 1
    To supply orthodontic information
  5. 1500Tooth SummaryOptional->Max 35
    To specify the status of individual teeth
  6. 1550PaperworkOptional->Max 10
    To identify the type or transmission or both of paperwork or supporting information
  7. 1600Contract InformationOptional->Max 1
    To specify basic data about the contract or contract line item
  8. 1650Disability InformationOptional->Max 1
    To supply disability information
  9. 1700Peer Review Organization or Utilization ReviewOptional->Max 1
    To specify the results of the utilization review
  10. 1750Monetary Amount InformationOptional->Max 40
    To indicate the total monetary amount
  11. 1800Reference InformationOptional->Max 30
    To specify identifying information
  12. 1850File InformationOptional->Max 10
    To transmit a fixed-format record or matrix contents
  13. 1900Note/Special InstructionOptional->Max 20
    To transmit information in a free-form format, if necessary, for comment or special instruction
  14. 1950Ambulance 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. 2000Chiropractic CertificationOptional->Max 1
    To supply information related to the chiropractic service rendered to a patient
  16. 2050Durable Medical Equipment CertificationOptional->Max 1
    To supply information regarding a physician's certification for durable medical equipment
  17. 2100Enteral or Parenteral Therapy CertificationOptional->Max 3
    To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy
  18. 2150Oxygen Therapy CertificationOptional->Max 1
    To supply information regarding certification of medical necessity for home oxygen therapy
  19. 2160Home Health Care CertificationOptional->Max 1
    To supply information related to the certification of a home health care patient
  20. 2190Pacemaker CertificationOptional->Max 9
    To supply information related to Pacemaker registry
  21. 2200Conditions IndicatorOptional->Max 100
    To supply information on conditions
  22. 2310Health Care Information CodesOptional->Max 25
    To supply information related to the delivery of health care
  23. 2400Quantity InformationOptional->Max 10
    To specify quantity information
  24. 2410Health Care PricingOptional->Max 1
    To specify pricing or repricing information about a health care claim or line item
  25. 2305 Loop Optional
    Repeat 6
    2420Home Health Treatment Plan CertificationMandatory->Max 1
    To supply information related to the home health care plan of treatment and services
    2430Health Care Services DeliveryOptional->Max 12
    To specify the delivery pattern of health care services
  26. 2310 Loop Optional
    Repeat 9
    2500Individual 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.
    2550Provider InformationOptional->Max 1
    To specify the identifying characteristics of a provider
    2600Additional Name InformationOptional->Max 2
    To specify additional names
    2650Party LocationOptional->Max 2
    To specify the location of the named party
    2700Geographic LocationOptional->Max 1
    To specify the geographic place of the named party
    2710Reference InformationOptional->Max 20
    To specify identifying information
    2750Administrative Communications ContactOptional->Max 2
    To identify a person or office to whom administrative communications should be directed
  27. 2320 Loop Optional
    Repeat 10
    2900Subscriber 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.
    2950Claims 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
    3000Monetary Amount InformationOptional->Max 15
    To indicate the total monetary amount
    3050Demographic InformationOptional->Max 1
    To supply demographic information
    3100Other Health Insurance InformationOptional->Max 1
    To specify information associated with other health insurance coverage
    3150Medicare Inpatient AdjudicationOptional->Max 1
    To provide claim-level data related to the adjudication of Medicare inpatient claims
    3200Medicare 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
    3250Individual 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.
    3300Additional Name InformationOptional->Max 2
    To specify additional names
    3320Party LocationOptional->Max 2
    To specify the location of the named party
    3400Geographic LocationOptional->Max 1
    To specify the geographic place of the named party
    3450Administrative Communications ContactOptional->Max 2
    To identify a person or office to whom administrative communications should be directed
    3500Date or Time or PeriodOptional->Max 9
    To specify any or all of a date, a time, or a time period
    3550Reference InformationOptional->Max >1
    To specify identifying information
  28. 2400 Loop Optional
    Repeat >1
    3650Transaction Set Line NumberMandatory->Max 1
    To reference a line number in a transaction set
    Loop 2400 contains Service Line information.
    3700Professional ServiceOptional->Max 1
    To specify the claim service detail for a Health Care professional
    3750Institutional ServiceOptional->Max 1
    To specify the claim service detail for a Health Care institution
    3800Dental ServiceOptional->Max 1
    To specify the claim service detail for dental work
    3820Tooth IdentificationOptional->Max 32
    To identify a tooth by number and, if applicable, one or more tooth surfaces
    3850Drug ServiceOptional->Max 1
    To specify the claim service detail for prescription drugs
    4000Durable Medical Equipment ServiceOptional->Max 1
    To specify the claim service detail for durable medical equipment
    4050Anesthesia ServiceOptional->Max 1
    To specify the claim service detail for anesthesia
    4100Drug AdjudicationOptional->Max 1
    To specify the claim service detail for drug services that have been adjudicated
    4150Health Care Information CodesOptional->Max 25
    To supply information related to the delivery of health care
    4200PaperworkOptional->Max 10
    To identify the type or transmission or both of paperwork or supporting information
    4250Ambulance 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.
    4300Chiropractic CertificationOptional->Max 5
    To supply information related to the chiropractic service rendered to a patient
    4350Durable Medical Equipment CertificationOptional->Max 1
    To supply information regarding a physician's certification for durable medical equipment
    4400Enteral or Parenteral Therapy CertificationOptional->Max 3
    To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy
    4450Oxygen Therapy CertificationOptional->Max 1
    To supply information regarding certification of medical necessity for home oxygen therapy
    4500Conditions IndicatorOptional->Max 3
    To supply information on conditions
    4550Date or Time or PeriodOptional->Max 15
    To specify any or all of a date, a time, or a time period
    4600Quantity InformationOptional->Max 5
    To specify quantity information
    4620MeasurementsOptional->Max 20
    To specify physical measurements or counts, including dimensions, tolerances, variances, and weights (See Figures Appendix for example of use of C001)
    4650Contract InformationOptional->Max 1
    To specify basic data about the contract or contract line item
    4700Reference InformationOptional->Max 30
    To specify identifying information
    4750Monetary Amount InformationOptional->Max 15
    To indicate the total monetary amount
    4800File InformationOptional->Max 10
    To transmit a fixed-format record or matrix contents
    4850Note/Special InstructionOptional->Max 10
    To transmit information in a free-form format, if necessary, for comment or special instruction
    4880Purchase ServiceOptional->Max 1
    To specify the information about services that are purchased
    4900Immunization StatusOptional->Max >1
    To provide the receiving school district or postsecondary institution with a notice of the immunization status of the student
    4910Health Care Services DeliveryOptional->Max 1
    To specify the delivery pattern of health care services
    4920Health Care PricingOptional->Max 1
    To specify pricing or repricing information about a health care claim or line item
    2410 Loop Optional
    Repeat >1
    4930Item IdentificationMandatory->Max 1
    To specify basic item identification data
    Loop 2410 contains compound drug components, quantities and prices.
    4940Pricing InformationOptional->Max 1
    To specify pricing information
    4950Reference InformationOptional->Max 1
    To specify identifying information
    2420 Loop Optional
    Repeat 10
    5000Individual 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.
    5050Provider InformationOptional->Max 1
    To specify the identifying characteristics of a provider
    5100Additional Name InformationOptional->Max 2
    To specify additional names
    5140Party LocationOptional->Max 2
    To specify the location of the named party
    5200Geographic LocationOptional->Max 1
    To specify the geographic place of the named party
    5250Reference InformationOptional->Max 20
    To specify identifying information
    5300Administrative Communications ContactOptional->Max 2
    To identify a person or office to whom administrative communications should be directed
    2430 Loop Optional
    Repeat >1
    5400Service 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.
    5450Claims 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
    5500Date or Time or PeriodOptional->Max 9
    To specify any or all of a date, a time, or a time period
    2440 Loop Optional
    Repeat >1
    5510Industry Code IdentificationMandatory->Max 1
    To identify standard industry codes
    Loop 2440 provides certificate of medical necessity information for the procedure identified in SV101 in position 2/3700.
    5520Supporting DocumentationMandatory->Max 99
    To specify information in response to a codified questionnaire document
    FRM segment provides question numbers and responses for the questions on the medical necessity information form identified in LQ position 551.
5550Transaction 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