EDI 837 Healthcare 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™ for Healthcare. You get the extensive features of our advanced EDI software with additional support for healthcare-specific transactions. Ready to see for yourself? Contact us for a demo.

EDI 837 Format

ISA*01*0000000000*01*0000000000*ZZ*ABCDEFGHIJKLMNO*ZZ*123456789012345*101127*1719*U*00400*000003438*0*P*> 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 Healthcare Claim Transaction Set (837) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to submit healthcare claim billing information, encounter information, or both, from providers of healthcare services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit healthcare 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 healthcare services within a specific healthcare/insurance industry segment. For purposes of this standard, providers of healthcare 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 healthcare/insurance industry segment.

Sources

Accredited Standards Committee X12. ASC X12 Standard [Table Data]. Data Interchange Standards Association, Inc., Falls Church, VA. http://www.x12.org