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Transaction Set
in
X12 Release 003030

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.

Heading

Sequence
Segment
Name
Max use
005
Transaction Set HeaderMandatory
Max 1
To indicate the start of a transaction set and to assign a control number
010
Beginning Segment
Max 1
To indicate the beginning of a transaction set.
015
Reference Numbers
Max 3
To specify identifying numbers.
1000 Loop
Repeat 10
020
Individual or Organizational Name
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 occurence to the loop as a form of identification. The added loop occurence must be the last occurence of the loop.
025
Additional Name Information
Max 2
To specify additional names or those longer than 35 characters in length
030
Address Information
Max 2
To specify the location of the named party
035
Geographic Location
Max 1
To specify the geographic place of the named party
040
Reference Numbers
Max 2
To specify identifying numbers.
045
Administrative Communications Contact
Max 2
To identify a person or office to whom administrative communications should be directed

Detail

Sequence
Segment
Name
Max use
2000 Loop
Repeat 100
005
Provider InformationMandatory
Max 1
To specify the identifying characteristics of a provider
See Figures Appendix for a detail structure of Table 2 of the 837 Transaction Set.
010
Currency
Max 1
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
2010 Loop
Repeat 2
015
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
Loop 2010 contains provider information: Billing Provider Information, Pay-To Provider
020
Additional Name Information
Max 2
To specify additional names or those longer than 35 characters in length
025
Address Information
Max 2
To specify the location of the named party
030
Geographic Location
Max 1
To specify the geographic place of the named party
035
Reference Numbers
Max 20
To specify identifying numbers.
040
Administrative Communications Contact
Max 2
To identify a person or office to whom administrative communications should be directed
2100 Loop
Repeat 99999
045
Subscriber InformationMandatory
Max 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.
050
Date or Time or Period
Max 5
To specify any or all of a date, a time, or a time period
2110 Loop
Repeat 10
055
Individual or Organizational Name
Max 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
060
Additional Name Information
Max 2
To specify additional names or those longer than 35 characters in length
065
Address Information
Max 2
To specify the location of the named party
070
Geographic Location
Max 1
To specify the geographic place of the named party
075
Demographic Information
Max 1
To supply demographic information
080
Administrative Communications Contact
Max 2
To identify a person or office to whom administrative communications should be directed
085
Reference Numbers
Max 5
To specify identifying numbers.
2200 Loop
Repeat 99
090
Patient InformationMandatory
Max 1
To supply patient information
2210 Loop
Repeat 10
095
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
Loop 2210 contains name and address information for: Patient, Patient's Legal Representative, Party Responsible for the Patient
100
Additional Name Information
Max 2
To specify additional names or those longer than 35 characters in length
105
Address Information
Max 2
To specify the location of the named party
110
Geographic Location
Max 1
To specify the geographic place of the named party
115
Demographic Information
Max 1
To supply demographic information
120
Administrative Communications Contact
Max 2
To identify a person or office to whom administrative communications should be directed
125
Reference Numbers
Max 5
To specify identifying numbers.
2300 Loop
Repeat 100
130
Health ClaimMandatory
Max 1
To specify basic data about the claim
135
Date or Time or Period
Max 40
To specify any or all of a date, a time, or a time period
140
Claim Codes
Max 1
To supply information specific to hospital claims
145
Orthodontic Information
Max 1
To supply orthodontic information
150
Tooth Summary
Max 35
To specify the status of individual teeth
155
Paperwork
Max 10
To identify the type and transmission of paperwork or supporting information
160
Contract Information
Max 1
To specify basic data about the contract
165
Disability Information
Max 1
To supply disability information
170
Peer Review Organization or Utilization Review
Max 1
To specify the results of the utilization review
175
Monetary Amount
Max 40
To indicate the total monetary amount.
180
Reference Numbers
Max 10
To specify identifying numbers.
185
File Information
Max 10
To transmit a fixed format record
The K3 segment contains information specific to any Federal, State or Plan changes.
190
Note/Special Instruction
Max 4
To transmit information in a free-form format, if necessary, for comment or special instruction
The NTE segment contains diagnosis description information and certification narrative information.
195
Ambulance Certification
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. Cerfication information at the claim level applies to all service lines of the claim, unless overridden by certification information at the service line level.
200
Chiropractic Certification
Max 1
To supply information to the chiropractic service rendered to a patient
205
Durable Medical Equipment Certification
Max 1
To supply information regarding a physician's certification for durable medical equipment
210
Enteral or Parenteral Therapy Certification
Max 3
To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy
215
Oxygen Therapy Certification
Max 1
To supply information regarding certification of medical necessity for home oxygen therapy
220
Certification Conditions
Max 3
To supply information on the conditions related to a certification
225
Procedure Codes
Max 25
To specify a procedure code and the date associated with it
230
Informational Values
Max 25
To specify a code and the amount, quantity associated with it, or both
235
Multi-Valued Characteristics
Max 30
To provide characteristics that may have multiple values
240
Quantity
Max 10
To specify quantity information.
245
Loop Header
Max 1
To indicate that the next segment begins a loop
2310 Loop
Repeat 9
250
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
Loop 2310 contains information about the provider rendering the service(s). This provider name and address information will apply to all service lines of the claim, unless overridden by provider information at the service line level. This information can also be facility identification information or oxygen therapy facility information.
255
Provider Information
Max 1
To specify the identifying characteristics of a provider
260
Additional Name Information
Max 2
To specify additional names or those longer than 35 characters in length
265
Address Information
Max 2
To specify the location of the named party
270
Geographic Location
Max 1
To specify the geographic place of the named party
275
Administrative Communications Contact
Max 2
To identify a person or office to whom administrative communications should be directed
280
Loop Trailer
Max 1
To indicate that the loop immediately preceding this segment is complete
2400 Loop
Repeat 10000
285
Assigned Number
Max 1
To reference a line number in a transaction set.
Loop 2400 contains Service Line information.
290
Professional Service
Max 1
To specify the claim service detail for a Health Care professional
295
Institutional Service
Max 1
To specify the claim service detail for a Health Care institution
300
Dental Service
Max 1
To specify the claim service detail for dental work
305
Drug Service
Max 1
To specify the claim service detail for prescription drugs
2410 Loop
Repeat 10
310
Item Identification
Max 1
To specify basic item identification data.
Loop 2410 contains compound drug components, quantities and prices.
315
Pricing Information
Max 1
To specify pricing information
320
Durable Medical Equipment Service
Max 1
To specify the claim service detail for durable medical equipment
325
Anesthesia Service
Max 1
To specify the claim service detail for anesthesia
330
Drug Adjudication
Max 1
To specify the claim service detail for drug services that have been adjudicated
335
Multi-Valued Characteristics
Max 5
To provide characteristics that may have multiple values
340
Paperwork
Max 10
To identify the type and transmission of paperwork or supporting information
345
Ambulance Certification
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.
350
Chiropractic Certification
Max 5
To supply information to the chiropractic service rendered to a patient
355
Durable Medical Equipment Certification
Max 1
To supply information regarding a physician's certification for durable medical equipment
360
Enteral or Parenteral Therapy Certification
Max 3
To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy
365
Oxygen Therapy Certification
Max 1
To supply information regarding certification of medical necessity for home oxygen therapy
370
Certification Conditions
Max 3
To supply information on the conditions related to a certification
375
Date or Time or Period
Max 15
To specify any or all of a date, a time, or a time period
380
Quantity
Max 5
To specify quantity information.
385
Contract Information
Max 1
To specify basic data about the contract
390
Reference Numbers
Max 10
To specify identifying numbers.
395
Monetary Amount
Max 15
To indicate the total monetary amount.
400
File Information
Max 10
To transmit a fixed format record
The K3 segment contains information specific to any Federal, State, or Plan changes.
405
Note/Special Instruction
Max 10
To transmit information in a free-form format, if necessary, for comment or special instruction
The NTE segment contains certification narrative information.
410
Purchase Service
Max 1
To specify the information about services that are purchased
415
Loop Header
Max 1
To indicate that the next segment begins a loop
2420 Loop
Repeat 10
420
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
Loop 2420 contains information about the provider rendering the service detailed on the service line. These segments override the information in the claim-level segments (within loop 2310), if the entity identifier codes in each segment are the same. This information can also be purchased service information or oxygen therapy facility information.
425
Provider Information
Max 1
To specify the identifying characteristics of a provider
430
Additional Name Information
Max 2
To specify additional names or those longer than 35 characters in length
435
Address Information
Max 2
To specify the location of the named party
440
Geographic Location
Max 1
To specify the geographic place of the named party
445
Administrative Communications Contact
Max 2
To identify a person or office to whom administrative communications should be directed
450
Loop Trailer
Max 1
To indicate that the loop immediately preceding this segment is complete
455
Loop Header
Max 1
To indicate that the next segment begins a loop
2500 Loop
Repeat 10
460
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
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.
465
Additional Name Information
Max 2
To specify additional names or those longer than 35 characters in length
470
Address Information
Max 2
To specify the location of the named party
475
Geographic Location
Max 1
To specify the geographic place of the named party
480
Administrative Communications Contact
Max 1
To identify a person or office to whom administrative communications should be directed
485
Subscriber Information
Max 1
To record claim information specific to the primary insured and the insurance carrier for that insured
490
Claim Adjudication
Max 1
To specify the adjudication codes for a claim service item
The CA1 segment contains crossover data.
495
Monetary Amount
Max 15
To indicate the total monetary amount.
500
Demographic Information
Max 1
To supply demographic information
505
Date or Time or Period
Max 2
To specify any or all of a date, a time, or a time period
510
Reference Numbers
Max 3
To specify identifying numbers.
515
Loop Trailer
Max 1
To indicate that the loop immediately preceding this segment is complete
520
Transaction 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).
Stedi is a registered trademark of Stedi, Inc. Stedi's EDI Reference and Mapping Guides are provided for marketing purposes and are free of charge. All names, logos, and brands of third parties listed on our site are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Our use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.
Stedi is a registered trademark of Stedi, Inc. Stedi's EDI Reference and Mapping Guides are provided for marketing purposes and are free of charge. All names, logos, and brands of third parties listed on our site are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Our use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.