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

  2. 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

  3. To specify identifying information

  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

    3. To specify the location of the named party

    4. To specify the geographic place of the named party

    5. To specify identifying information

    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 identify dependencies among and the content of hierarchically related groups of data segments

    2. To specify the identifying characteristics of a provider

    3. To record information specific to the primary insured and the insurance carrier for that insured

    4. To supply patient information

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

    6. To specify the currency (dollars, pounds, francs, etc.) used in a transaction

    7. 2010 Loop Optional
      Repeat 10
      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. To specify additional names

      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 specify identifying information

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

    8. 2300 Loop Optional
      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 or transmission or both of paperwork or supporting information

      7. To specify basic data about the contract or contract line item

      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 information

      12. To transmit a fixed-format record or matrix contents

      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 the certification of a home health care patient

      20. To supply information related to Pacemaker registry

      21. To supply information on conditions

      22. To supply information related to the delivery of health care

      23. To specify quantity information

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

      25. 2305 Loop Optional
        Repeat 6
        1. To supply information related to the home health care plan of treatment and services

        2. To specify the delivery pattern of health care services

      26. 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

        4. To specify the location of the named party

        5. To specify the geographic place of the named party

        6. To specify identifying information

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

      27. 2320 Loop Optional
        Repeat 10
        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.
        2. To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

        3. To indicate the total monetary amount

        4. To supply demographic information

        5. To specify information associated with other health insurance coverage

        6. To provide claim-level data related to the adjudication of Medicare inpatient claims

        7. To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting

        8. 2330 Loop Optional
          Repeat 10
          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.
          2. To specify additional names

          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 information

      28. 2400 Loop Optional
        Repeat >1
        1. To reference a line number in a transaction set

          Loop 2400 contains Service Line information.
        2. To specify the service line item detail for a health care professional

        3. To specify the service line item detail for a health care institution

        4. To specify the service line item detail for dental work

        5. To identify a tooth by number and, if applicable, one or more tooth surfaces

        6. To specify the claim service detail for prescription drugs

        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 supply information related to the delivery of health care

        11. To identify the type or transmission or both 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 physical measurements or counts, including dimensions, tolerances, variances, and weights (See Figures Appendix for example of use of C001)

        21. To specify basic data about the contract or contract line item

        22. To specify identifying information

        23. To indicate the total monetary amount

        24. To transmit a fixed-format record or matrix contents

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

        26. To specify the information about services that are purchased

        27. To provide the receiving school district or postsecondary institution with a notice of the immunization status of the student

        28. To specify the delivery pattern of health care services

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

        30. 2410 Loop Optional
          Repeat >1
          1. To specify basic item identification data

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

          3. To specify identifying information

        31. 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

          4. To specify the location of the named party

          5. To specify the geographic place of the named party

          6. To specify identifying information

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

        32. 2430 Loop Optional
          Repeat >1
          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.
          2. To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

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

        33. 2440 Loop Optional
          Repeat >1
          1. To identify standard industry codes

            Loop 2440 provides certificate of medical necessity information for the procedure identified in SV101 in position 2/3700.
          2. 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.
  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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