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EDI 837

EDI 837 Health Care Claim:

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.

Managing EDI transactions with full HIPAA 5010 compliance is a snap with EDI/HQ™ Healthcare. You get the extensive features of our advanced EDI software with additional support for healthcare-specific transactions. Ready to see for yourself? Download the EDI/HQ trial now.

EDI 837 Format:

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

EDI 837 Specification:

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.

Sources
Accredited Standards Committee X12. ASC X12 Standard [Table Data].
Data Interchange Standards Association, Inc., Falls Church, VA.

EDI 837 News:

Healthcare Transaction Status Requests

Tuesday, May 05, 2009

In today’s busy world, just trying to keep up is challenging. Busy health care professionals will appreciate an easy way to follow up on the claims they have submitted while awaiting payment. Did you know you can use the same software that you use to send your health care claims to also automatically send a request for status?

Page Title: Learn about the EDI 837 Health Care Claim