Product: X12 EDI

Transaction: 837

Article Link: http://help.truecommerce.com/en/articles/10258395-x12-837-health-care-claim

837 - Health Care Claim
FUNCTIONAL GROUP=HC

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.

SCHEMA

ST

Segment	Name	Position
ST	Transaction Set Header	0050
BHT	Beginning of Hierarchical Transaction	0100
REF	Reference Information	0150

1000

Segment	Name	Position
NM1	Individual or Organizational Name	0200
N2	Additional Name Information	0250
N3	Party Location	0300
N4	Geographic Location	0350
REF	Reference Information	0400
PER	Administrative Communications Contact	0450

2000

Segment	Name	Position
HL	Hierarchical Level	0010
PRV	Provider Information	0030
SBR	Subscriber Information	0050
PAT	Patient Information	0070
DTP	Date or Time or Period	0090
CUR	Currency	0100

2010

Segment	Name	Position
NM1	Individual or Organizational Name	0150
N2	Additional Name Information	0200
N3	Party Location	0250
N4	Geographic Location	0300
DMG	Demographic Information	0320
REF	Reference Information	0350
PER	Administrative Communications Contact	0400
LUI	Language Use	0500

2300

Segment	Name	Position
CLM	Health Claim	1300
DTP	Date or Time or Period	1350
CL1	Claim Codes	1400
DN1	Orthodontic Information	1450
DN2	Tooth Summary	1500
PWK	Paperwork	1550
CN1	Contract Information	1600
DSB	Disability Information	1650
UR	Peer Review Organization or Utilization Review	1700
AMT	Monetary Amount Information	1750
REF	Reference Information	1800
K3	File Information	1850
NTE	Note/Special Instruction	1900
CR1	Ambulance Certification	1950
CR2	Chiropractic Certification	2000
CR3	Durable Medical Equipment Certification	2050
CR4	Enteral or Parenteral Therapy Certification	2100
CR5	Oxygen Therapy Certification	2150
CR6	Home Health Care Certification	2160
CR8	Pacemaker Certification	2190
CRC	Conditions Indicator	2200
HI	Health Care Information Codes	2310
QTY	Quantity Information	2400
HCP	Health Care Pricing	2410

2305

Segment	Name	Position
CR7	Home Health Treatment Plan Certification	2420
HSD	Health Care Services Delivery	2430

2310

Segment	Name	Position
NM1	Individual or Organizational Name	2500
PRV	Provider Information	2550
N2	Additional Name Information	2600
N3	Party Location	2650
N4	Geographic Location	2700
REF	Reference Information	2710
PER	Administrative Communications Contact	2750

2320

Segment	Name	Position
SBR	Subscriber Information	2900
CAS	Claims Adjustment	2950
RAS	Reason Adjustment	2980
AMT	Monetary Amount Information	3000
DMG	Demographic Information	3050
OI	Other Health Insurance Information	3100
MIA	Inpatient Adjudication	3150
MOA	Outpatient Adjudication	3200

2330

Segment	Name	Position
NM1	Individual or Organizational Name	3250
N2	Additional Name Information	3300
N3	Party Location	3320
N4	Geographic Location	3400
PER	Administrative Communications Contact	3450
DTP	Date or Time or Period	3500
REF	Reference Information	3550

2400

Segment	Name	Position
LX	Transaction Set Line Number	3650
SV1	Professional Service	3700
SV2	Institutional Service	3750
SV3	Dental Service	3800
TOO	Tooth Identification	3820
SV4	Drug Service	3850
SV5	Durable Medical Equipment Service	4000
SV6	Anesthesia Service	4050
SV7	Drug Adjudication	4100
HI	Health Care Information Codes	4150
PWK	Paperwork	4200
CR1	Ambulance Certification	4250
CR2	Chiropractic Certification	4300
CR3	Durable Medical Equipment Certification	4350
CR4	Enteral or Parenteral Therapy Certification	4400
CR5	Oxygen Therapy Certification	4450
CRC	Conditions Indicator	4500
DTP	Date or Time or Period	4550
QTY	Quantity Information	4600
MEA	Measurements	4620
CN1	Contract Information	4650
REF	Reference Information	4700
AMT	Monetary Amount Information	4750
K3	File Information	4800
NTE	Note/Special Instruction	4850
PS1	Purchase Service	4880
IMM	Immunization Status	4900
HSD	Health Care Services Delivery	4910
HCP	Health Care Pricing	4920

2410

Segment	Name	Position
LIN	Item Identification	4930
CTP	Pricing Information	4940
REF	Reference Information	4950
SV4	Drug Service	4960
SV7	Drug Adjudication	4970

2420

Segment	Name	Position
NM1	Individual or Organizational Name	5000
PRV	Provider Information	5050
N2	Additional Name Information	5100
N3	Party Location	5140
N4	Geographic Location	5200
REF	Reference Information	5250
PER	Administrative Communications Contact	5300

2430

Segment	Name	Position
SVD	Service Line Adjudication	5400
CAS	Claims Adjustment	5450
RAS	Reason Adjustment	5480
DTP	Date or Time or Period	5500
AMT	Monetary Amount Information	5505

2440

Segment	Name	Position
LQ	Industry Code Identification	5510
FRM	Supporting Documentation	5520

SE

Segment	Name	Position
SE	Transaction Set Trailer	5550

COMMENTS

Notes
1/0200	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.
2/0150	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.
2/1950	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.
2/2500	Loop 2310 contains information about the claim level providers including, but not limited to; rendering, referring, and attending.
2/2900	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.
2/3250	Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.
2/3650	Loop 2400 contains Service Line information.
2/4250	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.
2/4930	Loop 2410 contains compound drug components, quantities and prices.
2/5000	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.
2/5400	SVD01 identifies the payer which adjudicated the corresponding service line and must match DE 67 in the NM109 position 325 for the payer.
2/5510	Loop 2440 provides certificate of medical necessity information for the procedure identified in SV101 in position 2/3700.
2/5520	FRM segment provides question numbers and responses for the questions on the medical necessity information form identified in LQ position 551.

rev 05/12/2024

837 - Health Care ClaimFUNCTIONAL GROUP=HC