x12 837 Health Care Claim

837 Specifications

The EDI 837 transaction set is the format established to meet HIPAA requirements for the electronic submission of healthcare claim information. The claim information included amounts to the following, for a single care encounter between patient and provider:

⇰ A description of the patient
⇰ The patient’s condition for which treatment was provided
⇰ The services provided
⇰ The cost of the treatment

As of March 31, 2012, healthcare providers must be compliant with version 5010 of the HIPAA EDI standards. The 5010 standards divide the 837 transaction set into three groups, as follows: 837P for professionals, 837I for institutions and 837D for dental practices. The 837 is no longer used by retail pharmacies.

This transaction set is sent by the providers to payers, which include insurance companies, health maintenance organizations (HMOs), preferred provider organizations (PPOs), or government agencies such as Medicare, Medicaid, etc. These transactions may be sent either directly or indirectly via clearinghouses. Health insurers and other payers send their payments and coordination of benefits information back to providers via the EDI 835 transaction set.

837 Example

ISA*00* *00* *ZZ*99999999999 *ZZ*888888888888 *111219*1340*^*00501*000001377*0*T~
GS*HC*99999999999*888888888888*20111219*1340*1377*X*005010X222~
ST*837*0001*005010X222~
BHT*0019*00*565743*20110523*154959*CH~
NM1*41*2*SAMPLE INC*****46*496103~
PER*IC*EDI DEPT*EM*FEEDBACK@1EDISOURCE.COM*TE*3305551212~
NM1*40*2*PPO BLUE*****46*54771~
HL*1**20*1~
PRV*BI*PXC*333600000X~
NM1*85*2*EDI SPECIALTY SAMPLE*****XX*123456789~
N3*1212 DEPOT DRIVE~
N4*CHICAGO*IL*606930159~
REF*EI*300123456~
HL*2*1*22*1~
SBR*P********BL~
NM1*IL*1*CUSTOMER*KAREN****MI*YYX123456789~
N3*228 PINEAPPLE CIRCLE~
N4*CORA*PA*15108~
DMG*D8*19630625*M~
NM1*PR*2*PPO BLUE*****PI*54771~
N3*PO BOX 12345~
N4*CAMP HILL*PA*17089~
HL*3*2*23*0~
PAT*19~
NM1*QC*1*CUSTOMER*COLE~
N3*228 PINEAPPLE CIRCLE~
N4*CORA*PA*15108~
DMG*D8*19940921*M~
CLM*945405*5332.54***12>B>1*Y*A*Y*Y*P~
HI*BK>2533~
LX*1~
SV1*HC>J2941*5332.54*UN*84***1~
DTP*472*RD8*20110511-20110511~
REF*6R*1099999731~
NTE*ADD*GENERIC 12MG CARTRIDGE~
LIN**N4*00013264681~
CTP****7*UN~
NM1*DK*1*PATIENT*DEBORAH****XX*12345679030~
N3*123 MAIN ST*APT B~
N4*PITTSBURGH*PA*152181871~
SE*39*0001~
GE*1*1377~
IEA*1*000001377~


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