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
- 0050Transaction Set HeaderMandatoryMax 1
To indicate the start of a transaction set and to assign a control number
- 0100Beginning of Hierarchical TransactionMandatoryMax 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 InformationOptionalMax 3
To specify identifying information
- 1000 Loop OptionalRepeat 10
- 0200Individual 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. - 0250Additional Name InformationOptionalMax 2
To specify additional names
- 0300Party LocationOptionalMax 2
To specify the location of the named party
- 0350Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 0400Reference InformationOptionalMax 2
To specify identifying information
- 0450Administrative Communications ContactOptionalMax 2
To identify a person or office to whom administrative communications should be directed
- 0200Individual or Organizational NameMandatoryMax 1
Detail
- 2000 Loop MandatoryRepeat >1
- 0010Hierarchical LevelMandatoryMax 1
To identify dependencies among and the content of hierarchically related groups of data segments
- 0030Provider InformationOptionalMax 1
To specify the identifying characteristics of a provider
- 0050Subscriber InformationOptionalMax 1
To record information specific to the primary insured and the insurance carrier for that insured
- 0070Patient InformationOptionalMax 1
To supply patient information
- 0090Date or Time or PeriodOptionalMax 5
To specify any or all of a date, a time, or a time period
- 0100CurrencyOptionalMax 1
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
- 2010 Loop OptionalRepeat 10
- 0150Individual or Organizational NameMandatoryMax 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. - 0200Additional Name InformationOptionalMax 2
To specify additional names
- 0250Party LocationOptionalMax 2
To specify the location of the named party
- 0300Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 0320Demographic InformationOptionalMax 1
To supply demographic information
- 0350Reference InformationOptionalMax 20
To specify identifying information
- 0400Administrative Communications ContactOptionalMax 2
To identify a person or office to whom administrative communications should be directed
- 0500Language UseOptionalMax 1
To specify language, type of usage, and proficiency or fluency
- 0150Individual or Organizational NameMandatoryMax 1
- 2300 Loop OptionalRepeat 100
- 1300Health ClaimMandatoryMax 1
To specify basic data about the claim
- 1350Date or Time or PeriodOptionalMax 150
To specify any or all of a date, a time, or a time period
- 1400Claim CodesOptionalMax 1
To supply information specific to hospital claims
- 1450Orthodontic InformationOptionalMax 1
To supply orthodontic information
- 1500Tooth SummaryOptionalMax 35
To specify the status of individual teeth
- 1550PaperworkOptionalMax 10
To identify the type or transmission or both of paperwork or supporting information
- 1600Contract InformationOptionalMax 1
To specify basic data about the contract or contract line item
- 1650Disability InformationOptionalMax 1
To supply disability information
- 1700Peer Review Organization or Utilization ReviewOptionalMax 1
To specify the results of the utilization review
- 1750Monetary Amount InformationOptionalMax 40
To indicate the total monetary amount
- 1800Reference InformationOptionalMax 30
To specify identifying information
- 1850File InformationOptionalMax 10
To transmit a fixed-format record or matrix contents
- 1900Note/Special InstructionOptionalMax 20
To transmit information in a free-form format, if necessary, for comment or special instruction
- 1950Ambulance 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. - 2000Chiropractic CertificationOptionalMax 1
To supply information related to the chiropractic service rendered to a patient
- 2050Durable Medical Equipment CertificationOptionalMax 1
To supply information regarding a physician's certification for durable medical equipment
- 2100Enteral or Parenteral Therapy CertificationOptionalMax 3
To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy
- 2150Oxygen Therapy CertificationOptionalMax 1
To supply information regarding certification of medical necessity for home oxygen therapy
- 2160Home Health Care CertificationOptionalMax 1
To supply information related to the certification of a home health care patient
- 2190Implant CertificationOptionalMax 9
To supply information related to medical implant registries
- 2200Conditions IndicatorOptionalMax 100
To supply information on conditions
- 2310Health Care Information CodesOptionalMax 25
To supply information related to the delivery of health care
- 2400Quantity InformationOptionalMax 10
To specify quantity information
- 2410Health Care PricingOptionalMax 1
To specify pricing or repricing information about a health care claim or line item
- 2305 Loop OptionalRepeat 6
- 2420Home Health Treatment Plan CertificationMandatoryMax 1
To supply information related to the home health care plan of treatment and services
- 2430Health Care Services DeliveryOptionalMax 12
To specify the delivery pattern of health care services
- 2420Home Health Treatment Plan CertificationMandatoryMax 1
- 2310 Loop OptionalRepeat 9
- 2500Individual or Organizational NameMandatoryMax 1
To supply the full name of an individual or organizational entity
Loop 2310 contains information about the claim level providers including, but not limited to: rendering, referring, and attending. - 2550Provider InformationOptionalMax 1
To specify the identifying characteristics of a provider
- 2600Additional Name InformationOptionalMax 2
To specify additional names
- 2650Party LocationOptionalMax 2
To specify the location of the named party
- 2700Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 2710Reference InformationOptionalMax 20
To specify identifying information
- 2750Administrative Communications ContactOptionalMax 2
To identify a person or office to whom administrative communications should be directed
- 2500Individual or Organizational NameMandatoryMax 1
- 2320 Loop OptionalRepeat 10
- 2900Subscriber 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. - 2950Claims 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
- 2980Reason AdjustmentOptionalMax 99
To supply Claim Adjustment Reason Codes and amounts as needed for an entire claim or for a particular service within the claim being paid
- 3000Monetary Amount InformationOptionalMax 15
To indicate the total monetary amount
- 3050Demographic InformationOptionalMax 1
To supply demographic information
- 3100Other Health Insurance InformationOptionalMax 1
To specify information associated with other health insurance coverage
- 3150Inpatient AdjudicationOptionalMax 1
To provide claim level data related to the adjudication of inpatient claims
- 3200Outpatient AdjudicationOptionalMax 1
To provide claim level data related to the adjudication of outpatient claims
- 2330 Loop OptionalRepeat 10
- 3250Individual 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. - 3300Additional Name InformationOptionalMax 2
To specify additional names
- 3320Party LocationOptionalMax 2
To specify the location of the named party
- 3400Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 3450Administrative Communications ContactOptionalMax 2
To identify a person or office to whom administrative communications should be directed
- 3500Date or Time or PeriodOptionalMax 9
To specify any or all of a date, a time, or a time period
- 3550Reference InformationOptionalMax >1
To specify identifying information
- 3250Individual or Organizational NameMandatoryMax 1
- 2900Subscriber InformationMandatoryMax 1
- 2400 Loop OptionalRepeat >1
- 3650Transaction Set Line NumberMandatoryMax 1
To reference a line number in a transaction set
Loop 2400 contains Service Line information. - 3700Professional ServiceOptionalMax 1
To specify the service line item detail for a health care professional
- 3750Institutional ServiceOptionalMax 1
To specify the service line item detail for a health care institution
- 3800Dental ServiceOptionalMax 1
To specify the service line item detail for dental work
- 3820Tooth IdentificationOptionalMax 32
To identify a tooth by number and, if applicable, one or more tooth surfaces
- 3850Drug ServiceOptionalMax 1
To specify the claim service detail for prescription drugs
- 4000Durable Medical Equipment ServiceOptionalMax 1
To specify the claim service detail for durable medical equipment
- 4050Anesthesia ServiceOptionalMax 1
To specify the claim service detail for anesthesia
- 4100Drug AdjudicationOptionalMax 1
To specify the claim service detail for drug services that have been adjudicated
- 4150Health Care Information CodesOptionalMax 25
To supply information related to the delivery of health care
- 4200PaperworkOptionalMax 10
To identify the type or transmission or both of paperwork or supporting information
- 4250Ambulance 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. - 4300Chiropractic CertificationOptionalMax 5
To supply information related to the chiropractic service rendered to a patient
- 4350Durable Medical Equipment CertificationOptionalMax 1
To supply information regarding a physician's certification for durable medical equipment
- 4400Enteral or Parenteral Therapy CertificationOptionalMax 3
To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy
- 4450Oxygen Therapy CertificationOptionalMax 1
To supply information regarding certification of medical necessity for home oxygen therapy
- 4500Conditions IndicatorOptionalMax 3
To supply information on conditions
- 4550Date or Time or PeriodOptionalMax 15
To specify any or all of a date, a time, or a time period
- 4600Quantity InformationOptionalMax 5
To specify quantity information
- 4620MeasurementsOptionalMax 20
To specify physical measurements or counts, including dimensions, tolerances, variances, and weights (See Figures Appendix for example of use of C001)
- 4650Contract InformationOptionalMax 1
To specify basic data about the contract or contract line item
- 4700Reference InformationOptionalMax 30
To specify identifying information
- 4750Monetary Amount InformationOptionalMax 15
To indicate the total monetary amount
- 4800File InformationOptionalMax 10
To transmit a fixed-format record or matrix contents
- 4850Note/Special InstructionOptionalMax 10
To transmit information in a free-form format, if necessary, for comment or special instruction
- 4880Purchase ServiceOptionalMax 1
To specify the information about services that are purchased
- 4900Immunization StatusOptionalMax >1
To provide the receiving school district or postsecondary institution with a notice of the immunization status of the student
- 4910Health Care Services DeliveryOptionalMax 1
To specify the delivery pattern of health care services
- 4920Health Care PricingOptionalMax 1
To specify pricing or repricing information about a health care claim or line item
- 2410 Loop OptionalRepeat >1
- 4930Item IdentificationMandatoryMax 1
To specify basic item identification data
Loop 2410 contains compound drug components, quantities and prices. - 4940Pricing InformationOptionalMax 1
To specify pricing information
- 4950Reference InformationOptionalMax 1
To specify identifying information
- 4960Drug ServiceOptionalMax 1
To specify the claim service detail for prescription drugs
- 4970Drug AdjudicationOptionalMax 1
To specify the claim service detail for drug services that have been adjudicated
- 4930Item IdentificationMandatoryMax 1
- 2420 Loop OptionalRepeat 10
- 5000Individual or Organizational NameMandatoryMax 1
To supply the full name of an individual or organizational entity
Loop 2420 contains information about the service line providers including, but not limited to: rendering, referring and attending. These segments override the information in the claim - level segments if the entity identifier codes in each NM1 segment are the same. - 5050Provider InformationOptionalMax 1
To specify the identifying characteristics of a provider
- 5100Additional Name InformationOptionalMax 2
To specify additional names
- 5140Party LocationOptionalMax 2
To specify the location of the named party
- 5200Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 5250Reference InformationOptionalMax 20
To specify identifying information
- 5300Administrative Communications ContactOptionalMax 2
To identify a person or office to whom administrative communications should be directed
- 5000Individual or Organizational NameMandatoryMax 1
- 2430 Loop OptionalRepeat >1
- 5400Service 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 a Payer ID specified in DE 67 in the NM109 of the 2330 loop. - 5450Claims 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
- 5480Reason AdjustmentOptionalMax 99
To supply Claim 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 PeriodOptionalMax 9
To specify any or all of a date, a time, or a time period
- 5505Monetary Amount InformationOptionalMax 20
To indicate the total monetary amount
- 5507InformationOptionalMax 99
To report information
- 5400Service Line AdjudicationMandatoryMax 1
- 2440 Loop OptionalRepeat >1
- 5510Industry Code IdentificationMandatoryMax 1
To identify standard industry codes
- 5520Supporting DocumentationMandatoryMax 99
To specify information in response to a codified questionnaire document
- 5510Industry Code IdentificationMandatoryMax 1
- 3650Transaction Set Line NumberMandatoryMax 1
- 1300Health ClaimMandatoryMax 1
- 0010Hierarchical LevelMandatoryMax 1
- 5550Transaction 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