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
  1. To indicate the start of a transaction set and to assign a control number

  2. To indicate the beginning of a transaction set.

  3. To specify identifying numbers.

  4. 1000 Loop Optional
    Repeat 10
    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. To specify additional names or those longer than 35 characters in length

    3. To specify the location of the named party

    4. To specify the geographic place of the named party

    5. To specify identifying numbers.

    6. To identify a person or office to whom administrative communications should be directed

Detail

Position
Segment
Name
Max use
  1. 2000 Loop Mandatory
    Repeat >1
    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. To specify the currency (dollars, pounds, francs, etc.) used in a transaction

    3. 2010 Loop Optional
      Repeat 2
      1. To supply the full name of an individual or organizational entity

        Loop 2010 contains provider information: Billing Provider Information, Pay-To Provider
      2. To specify additional names or those longer than 35 characters in length

      3. To specify the location of the named party

      4. To specify the geographic place of the named party

      5. To specify identifying numbers.

      6. To identify a person or office to whom administrative communications should be directed

    4. 2100 Loop Mandatory
      Repeat 99999
      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. To specify any or all of a date, a time, or a time period

      3. 2110 Loop Optional
        Repeat 10
        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
        2. To specify additional names or those longer than 35 characters in length

        3. To specify the location of the named party

        4. To specify the geographic place of the named party

        5. To supply demographic information

        6. To identify a person or office to whom administrative communications should be directed

        7. To specify identifying numbers.

      4. 2200 Loop Mandatory
        Repeat 99
        1. To supply patient information

        2. 2210 Loop Optional
          Repeat 10
          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.
          2. To specify additional names or those longer than 35 characters in length

          3. To specify the location of the named party

          4. To specify the geographic place of the named party

          5. To supply demographic information

          6. To identify a person or office to whom administrative communications should be directed

          7. To specify identifying numbers.

        3. 2300 Loop Mandatory
          Repeat 100
          1. To specify basic data about the claim

          2. To specify any or all of a date, a time, or a time period

          3. To supply information specific to hospital claims

          4. To supply orthodontic information

          5. To specify the status of individual teeth

          6. To identify the type and transmission of paperwork or supporting information

          7. To specify basic data about the contract

          8. To supply disability information

          9. To specify the results of the utilization review

          10. To indicate the total monetary amount.

          11. To specify identifying numbers.

          12. To transmit a fixed format record

          13. To transmit information in a free-form format, if necessary, for comment or special instruction

          14. 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. To supply information related to the chiropractic service rendered to a patient

          16. To supply information regarding a physician's certification for durable medical equipment

          17. To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy

          18. To supply information regarding certification of medical necessity for home oxygen therapy

          19. To supply information related to Pacemaker registry.

          20. To supply information on conditions

          21. To specify medical procedures codes and the dates associated with them

          22. To specify a code and the amount, quantity associated with it, or both

          23. To provide characteristics that may have multiple values

          24. To specify quantity information.

          25. To specify pricing or repricing information about a health care claim or line item

          26. To indicate that the next segment begins a loop

          27. 2310 Loop Optional
            Repeat 9
            1. To supply the full name of an individual or organizational entity

              Loop 2310 contains information about the rendering, referring, or attending provider.
            2. To specify the identifying characteristics of a provider

            3. To specify additional names or those longer than 35 characters in length

            4. To specify the location of the named party

            5. To specify the geographic place of the named party

            6. To identify a person or office to whom administrative communications should be directed

          28. To indicate that the loop immediately preceding this segment is complete

          29. 2400 Loop Optional
            Repeat 10000
            1. To reference a line number in a transaction set.

              Loop 2400 contains Service Line information.
            2. To specify the claim service detail for a Health Care professional

            3. To specify the claim service detail for a Health Care institution

            4. To specify the claim service detail for dental work

            5. To specify the claim service detail for prescription drugs

            6. 2410 Loop Optional
              Repeat 10
              1. To specify basic item identification data.

                Loop 2410 contains compound drug components, quantities and prices.
              2. To specify pricing information

            7. To specify the claim service detail for durable medical equipment

            8. To specify the claim service detail for anesthesia

            9. To specify the claim service detail for drug services that have been adjudicated

            10. To provide characteristics that may have multiple values

            11. To identify the type and transmission of paperwork or supporting information

            12. 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.
            13. To supply information related to the chiropractic service rendered to a patient

            14. To supply information regarding a physician's certification for durable medical equipment

            15. To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy

            16. To supply information regarding certification of medical necessity for home oxygen therapy

            17. To supply information on conditions

            18. To specify any or all of a date, a time, or a time period

            19. To specify quantity information.

            20. To specify basic data about the contract

            21. To specify identifying numbers.

            22. To indicate the total monetary amount.

            23. To transmit a fixed format record

            24. To transmit information in a free-form format, if necessary, for comment or special instruction

            25. To specify the information about services that are purchased

            26. To specify pricing or repricing information about a health care claim or line item

            27. To indicate that the next segment begins a loop

            28. 2420 Loop Optional
              Repeat 10
              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.
              2. To specify the identifying characteristics of a provider

              3. To specify additional names or those longer than 35 characters in length

              4. To specify the location of the named party

              5. To specify the geographic place of the named party

              6. To identify a person or office to whom administrative communications should be directed

            29. To indicate that the loop immediately preceding this segment is complete

          30. To indicate that the next segment begins a loop

          31. 2500 Loop Optional
            Repeat 10
            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.
            2. To specify the adjudication codes for a claim service item

            3. To indicate the total monetary amount.

            4. To supply demographic information

            5. To specify information associated with other health insurance coverage

            6. 2510 Loop Optional
              Repeat 10
              1. To supply the full name of an individual or organizational entity

              2. To specify additional names or those longer than 35 characters in length

              3. To specify the location of the named party

              4. To specify the geographic place of the named party

              5. To identify a person or office to whom administrative communications should be directed

              6. To specify any or all of a date, a time, or a time period

              7. To specify identifying numbers.

          32. To indicate that the loop immediately preceding this segment is complete

  2. 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

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