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Transaction Set
in
X12 Release 004020

837 Health Care Claim

Functional Group HC

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 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.

Heading

Sequence
Segment
Name
Max use
0050
Transaction Set HeaderMandatory
Max 1
To indicate the start of a transaction set and to assign a control number
0100
Beginning 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
0150
Reference Identification
Max 3
To specify identifying information
1000 Loop
Repeat 10
0200
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 occurrence to the loop as a form of identification. The added loop occurrence must be the last occurrence of the loop.
0250
Additional Name Information
Max 2
To specify additional names
0300
Address Information
Max 2
To specify the location of the named party
0350
Geographic Location
Max 1
To specify the geographic place of the named party
0400
Reference Identification
Max 2
To specify identifying information
0450
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 >1
0010
Hierarchical LevelMandatory
Max 1
To identify dependencies among and the content of hierarchically related groups of data segments
0030
Provider Information
Max 1
To specify the identifying characteristics of a provider
0050
Subscriber Information
Max 1
To record information specific to the primary insured and the insurance carrier for that insured
0070
Patient Information
Max 1
To supply patient information
0090
Date or Time or Period
Max 5
To specify any or all of a date, a time, or a time period
0100
Currency
Max 1
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
2010 Loop
Repeat 10
0150
Individual or Organizational Name
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.
0200
Additional Name Information
Max 2
To specify additional names
0250
Address Information
Max 2
To specify the location of the named party
0300
Geographic Location
Max 1
To specify the geographic place of the named party
0320
Demographic Information
Max 1
To supply demographic information
0350
Reference Identification
Max 20
To specify identifying information
0400
Administrative Communications Contact
Max 2
To identify a person or office to whom administrative communications should be directed
2300 Loop
Repeat 100
1300
Health Claim
Max 1
To specify basic data about the claim
1350
Date or Time or Period
Max 150
To specify any or all of a date, a time, or a time period
1400
Claim Codes
Max 1
To supply information specific to hospital claims
1450
Orthodontic Information
Max 1
To supply orthodontic information
1500
Tooth Summary
Max 35
To specify the status of individual teeth
1550
Paperwork
Max 10
To identify the type or transmission or both of paperwork or supporting information
1600
Contract Information
Max 1
To specify basic data about the contract or contract line item
1650
Disability Information
Max 1
To supply disability information
1700
Peer Review Organization or Utilization Review
Max 1
To specify the results of the utilization review
1750
Monetary Amount
Max 40
To indicate the total monetary amount
1800
Reference Identification
Max 30
To specify identifying information
1850
File Information
Max 10
To transmit a fixed-format record or matrix contents
1900
Note/Special Instruction
Max 20
To transmit information in a free-form format, if necessary, for comment or special instruction
1950
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.
2000
Chiropractic Certification
Max 1
To supply information related to the chiropractic service rendered to a patient
2050
Durable Medical Equipment Certification
Max 1
To supply information regarding a physician's certification for durable medical equipment
2100
Enteral or Parenteral Therapy Certification
Max 3
To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy
2150
Oxygen Therapy Certification
Max 1
To supply information regarding certification of medical necessity for home oxygen therapy
2160
Home Health Care Certification
Max 1
To supply information related to the certification of a home health care patient
2190
Pacemaker Certification
Max 9
To supply information related to Pacemaker registry
2200
Conditions Indicator
Max 100
To supply information on conditions
2310
Health Care Information Codes
Max 25
To supply information related to the delivery of health care
2400
Quantity
Max 10
To specify quantity information
2410
Health Care Pricing
Max 1
To specify pricing or repricing information about a health care claim or line item
2305 Loop
Repeat 6
2420
Home Health Treatment Plan Certification
Max 1
To supply information related to the home health care plan of treatment and services
2430
Health Care Services Delivery
Max 12
To specify the delivery pattern of health care services
2310 Loop
Repeat 9
2500
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
Loop 2310 contains information about the rendering, referring, or attending provider.
2550
Provider Information
Max 1
To specify the identifying characteristics of a provider
2600
Additional Name Information
Max 2
To specify additional names
2650
Address Information
Max 2
To specify the location of the named party
2700
Geographic Location
Max 1
To specify the geographic place of the named party
2710
Reference Identification
Max 20
To specify identifying information
2750
Administrative Communications Contact
Max 2
To identify a person or office to whom administrative communications should be directed
2320 Loop
Repeat 10
2900
Subscriber Information
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.
2950
Claims Adjustment
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
3000
Monetary Amount
Max 15
To indicate the total monetary amount
3050
Demographic Information
Max 1
To supply demographic information
3100
Other Health Insurance Information
Max 1
To specify information associated with other health insurance coverage
3150
Medicare Inpatient Adjudication
Max 1
To provide claim-level data related to the adjudication of Medicare inpatient claims
3200
Medicare Outpatient Adjudication
Max 1
To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting
2330 Loop
Repeat 10
3250
Individual or Organizational Name
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.
3300
Additional Name Information
Max 2
To specify additional names
3320
Address Information
Max 2
To specify the location of the named party
3400
Geographic Location
Max 1
To specify the geographic place of the named party
3450
Administrative Communications Contact
Max 2
To identify a person or office to whom administrative communications should be directed
3500
Date or Time or Period
Max 9
To specify any or all of a date, a time, or a time period
3550
Reference Identification
Max >1
To specify identifying information
2400 Loop
Repeat >1
3650
Assigned Number
Max 1
To reference a line number in a transaction set
Loop 2400 contains Service Line information.
3700
Professional Service
Max 1
To specify the claim service detail for a Health Care professional
3750
Institutional Service
Max 1
To specify the claim service detail for a Health Care institution
3800
Dental Service
Max 1
To specify the claim service detail for dental work
3820
Tooth Identification
Max 32
To identify a tooth by number and, if applicable, one or more tooth surfaces
3850
Drug Service
Max 1
To specify the claim service detail for prescription drugs
4000
Durable Medical Equipment Service
Max 1
To specify the claim service detail for durable medical equipment
4050
Anesthesia Service
Max 1
To specify the claim service detail for anesthesia
4100
Drug Adjudication
Max 1
To specify the claim service detail for drug services that have been adjudicated
4150
Health Care Information Codes
Max 25
To supply information related to the delivery of health care
4200
Paperwork
Max 10
To identify the type or transmission or both of paperwork or supporting information
4250
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.
4300
Chiropractic Certification
Max 5
To supply information related to the chiropractic service rendered to a patient
4350
Durable Medical Equipment Certification
Max 1
To supply information regarding a physician's certification for durable medical equipment
4400
Enteral or Parenteral Therapy Certification
Max 3
To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy
4450
Oxygen Therapy Certification
Max 1
To supply information regarding certification of medical necessity for home oxygen therapy
4500
Conditions Indicator
Max 3
To supply information on conditions
4550
Date or Time or Period
Max 15
To specify any or all of a date, a time, or a time period
4600
Quantity
Max 5
To specify quantity information
4620
Measurements
Max 20
To specify physical measurements or counts, including dimensions, tolerances, variances, and weights (See Figures Appendix for example of use of C001)
4650
Contract Information
Max 1
To specify basic data about the contract or contract line item
4700
Reference Identification
Max 30
To specify identifying information
4750
Monetary Amount
Max 15
To indicate the total monetary amount
4800
File Information
Max 10
To transmit a fixed-format record or matrix contents
4850
Note/Special Instruction
Max 10
To transmit information in a free-form format, if necessary, for comment or special instruction
4880
Purchase Service
Max 1
To specify the information about services that are purchased
4900
Immunization Status Code
Max >1
To provide the receiving school district or postsecondary institution with a notice of the immunization status of the student
4910
Health Care Services Delivery
Max 1
To specify the delivery pattern of health care services
4920
Health Care Pricing
Max 1
To specify pricing or repricing information about a health care claim or line item
2410 Loop
Repeat >1
4930
Item Identification
Max 1
To specify basic item identification data
Loop 2410 contains compound drug components, quantities and prices.
4940
Pricing Information
Max 1
To specify pricing information
4950
Reference Identification
Max 1
To specify identifying information
2420 Loop
Repeat 10
5000
Individual or Organizational Name
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.
5050
Provider Information
Max 1
To specify the identifying characteristics of a provider
5100
Additional Name Information
Max 2
To specify additional names
5140
Address Information
Max 2
To specify the location of the named party
5200
Geographic Location
Max 1
To specify the geographic place of the named party
5250
Reference Identification
Max 20
To specify identifying information
5300
Administrative Communications Contact
Max 2
To identify a person or office to whom administrative communications should be directed
2430 Loop
Repeat >1
5400
Service Line Adjudication
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.
5450
Claims Adjustment
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
5500
Date or Time or Period
Max 9
To specify any or all of a date, a time, or a time period
2440 Loop
Repeat 1
5510
Industry Code
Max 1
Code to transmit standard industry codes
Loop 2440 provides certificate of medical necessity information for the procedure identified in SV101 in position 2/3700.
5520
Supporting 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.
5550
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.