837

Health Care Claim: Institutional

Functional Group=HC

This Standard 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.

Not Defined:

 

Pos

Id

Segment Name

Req

Max Use

Repeat

Notes

Usage

 

 

 

 

 

 

ISA

Interchange Control Header

M

1

 

 

Required

       

 

 

GS

Functional Group Header

M

1

 

 

Required

       

Heading:

 

Pos

Id

Segment Name

Req

Max Use

Repeat

Notes

Usage

 

 

 

 

 

005

ST

Transaction Set Header

M

1

 

 

Required

       

 

010

BHT

Beginning of Hierarchical Transaction

M

1

 

 

Required

       

 

015

REF

Transmission Type Identification

O

1

 

 

Required

       

LOOP ID - 1000A

 

 

1

N1/020L

 

 

 

 

 

 

020

NM1

Submitter Name

O

1

 

N1/020

Required

       

 

045

PER

Submitter EDI Contact Information

O

2

 

 

Required

       

LOOP ID - 1000B

 

 

1

N1/020L

 

 

 

 

 

 

020

NM1

Receiver Name

O

1

 

N1/020

Required

       

Detail:

 

Pos

Id

Segment Name

Req

Max Use

Repeat

Notes

Usage

 

 

 

 

LOOP ID - 2000A

 

 

>1

 

 

 

 

 

 

 

001

HL

Billing/Pay-To Provider Hierarchical Level

M

1

 

 

Required

       

LOOP ID - 2010AA

 

 

1

N2/015L

 

 

 

 

 

 

015

NM1

Billing Provider Name

O

1

 

N2/015

Required

       

 

025

N3

Billing Provider Address

O

1

 

 

Required

       

 

030

N4

Billing Provider City/State/ZIP Code

O

1

 

 

Required

       

 

035

REF

Billing Provider Secondary Identification

O

8

 

 

Situational

       

LOOP ID - 2000B

 

 

>1

 

 

 

 

 

 

 

001

HL

Subscriber Hierarchical Level

M

1

 

 

Required

       

LOOP ID - 2010BA

 

 

1

N2/015L

 

 

 

 

 

 

015

NM1

Subscriber Name

O

1

 

N2/015

Required

       

 

025

N3

Subscriber Address

O

1

 

 

Situational

       

 

030

N4

Subscriber City/State/ZIP Code

O

1

 

 

Situational

       

 

032

DMG

Subscriber Demographic Information

O

1

 

 

Situational

       

LOOP ID - 2010BC

 

 

1

N2/015L

 

 

 

 

 

 

015

NM1

Payer Name

O

1

 

N2/015

Required

       

 

025

N3

Payer Address

O

1

 

 

Situational

       

 

030

N4

Payer City/State/ZIP Code

O

1

 

 

Situational

       

 

035

REF

Payer Secondary Identification

O

3

 

 

Situational

       

LOOP ID - 2300

 

 

100

 

 

 

 

 

 

 

130

CLM

Claim information

O

1

 

 

Required

       

 

135

DTP

Discharge Hour

O

1

 

 

Situational

       

 

135

DTP

Statement Dates

O

1

 

 

Required

       

 

135

DTP

Admission Date/Hour

O

1

 

 

Situational

       

 

140

CL1

Institutional Claim Code

O

1

 

 

Situational

       

 

155

PWK

Claim Supplemental Information

O

10

 

 

Situational

       

 

160

CN1

Contract Information

O

1

 

 

Situational

       

 

175

AMT

Payer Estimated Amount Due

O

1

 

 

Situational

       

 

175

AMT

Patient Estimated Amount Due

O

1

 

 

Situational

       

 

175

AMT

Patient Paid Amount

O

1

 

 

Situational

       

 

180

REF

Document Identification Code

O

2

 

 

Situational

       

 

180

REF

Original Reference Number (ICN/DCN)

O

1

 

 

Situational

       

 

180

REF

Investigational Device Exemption Number

O

1

 

 

Situational

       

 

180

REF

Service Authorization Exception Code

O

1

 

 

Situational

       

 

180

REF

Peer Review Organization (PRO) Approval Number

O

1

 

 

Situational

       

 

180

REF

Prior Authorization or Referral Number

O

2

 

 

Situational

       

 

180

REF

Medical Record Number

O

1

 

 

Situational

       

 

190

NTE

Claim Note

O

10

 

 

Situational

       

 

216

CR6

Home Health Care Information

O

1

 

 

Situational

       

 

220

CRC

Home Health Functional Limitations

O

3

 

 

Situational

       

 

220

CRC

Home Health Activities Permitted

O

3

 

 

Situational

       

 

220

CRC

Home Health Mental Status

O

2

 

 

Situational

       

 

231

HI

Principal, Admitting, E-Code and Patient Reason For Visit Diagnosis Information

O

1

 

 

Situational

       

 

231

HI

Diagnosis Related Group (DRG) Information

O

1

 

 

Situational

       

 

231

HI

Other Diagnosis Information

O

2

 

 

Situational

       

 

231

HI

Principal Procedure Information

O

1

 

 

Situational

       

 

231

HI

Other Procedure Information

O

2

 

 

Situational

       

 

231

HI

Occurrence Span Information

O

2

 

 

Situational

       

 

231

HI

Occurrence Information

O

2

 

 

Situational

       

 

231

HI

Value Information

O

2

 

 

Situational

       

 

231

HI

Condition Information

O

2

 

 

Situational

       

 

231

HI

Treatment Code Information

O

2

 

 

Situational

       

 

240

QTY

Claim Quantity

O

4

 

 

Situational

       

LOOP ID - 2305

 

 

6

 

 

 

 

 

 

 

242

CR7

Home Health Care Plan Information

O

1

 

 

Situational

       

 

243

HSD

Health Care Services Delivery

O

12

 

 

Situational

       

LOOP ID - 2310A

 

 

1

N2/250L

 

 

 

 

 

 

250

NM1

Attending Physician Name

O

1

 

N2/250

Situational

       

 

271

REF

Attending Physician Secondary Identification

O

5

 

 

Situational

       

LOOP ID - 2310B

 

 

1

N2/250L

 

 

 

 

 

 

250

NM1

Operating Physician Name

O

1

 

N2/250

Situational

       

 

271

REF

Operating Physician Secondary Identification

O

5

 

 

Situational

       

LOOP ID - 2310C

 

 

1

N2/250L

 

 

 

 

 

 

250

NM1

Other Provider Name

O

1

 

N2/250

Situational

       

 

271

REF

Other Provider Secondary Identification

O

5

 

 

Situational

       

LOOP ID - 2310E

 

 

1

N2/250L

 

 

 

 

 

 

250

NM1

Service Facility Name

O

1

 

N2/250

Situational

       

 

265

N3

Service Facility Address

O

1

 

 

Required

       

 

270

N4

Service Facility City/State/Zip Code

O

1

 

 

Required

       

 

271

REF

Service Facility Secondary Identification

O

5

 

 

Situational

       

LOOP ID - 2320

 

 

10

N2/290L

 

 

 

 

 

 

290

SBR

Other Subscriber Information

O

1

 

N2/290

Situational

       

 

295

CAS

Claim Level Adjustment

O

5

 

 

Situational

       

 

300

AMT

Payer Prior Payment

O

1

 

 

Situational

       

 

300

AMT

Diagnostic Related Group (DRG) Outlier Amount

O

1

 

 

Situational

       

 

300

AMT

Medicare Paid Amount - 100%

O

1

 

 

Situational

       

 

300

AMT

Medicare Paid Amount - 80%

O

1

 

 

Situational

       

 

305

DMG

Other Subscriber Demographic Information

O

1

 

 

Situational

       

 

310

OI

Other Insurance Coverage Information

O

1

 

 

Required

       

LOOP ID - 2330A

 

 

1

N2/325L

 

 

 

 

 

 

325

NM1

Other Subscriber Name

O

1

 

N2/325

Required

       

 

332

N3

Other Subscriber Address

O

1

 

 

Situational

       

 

340

N4

Other Subscriber City/State/ZIP Code

O

1

 

 

Situational

       

 

355

REF

Other Subscriber Secondary Information

O

3

 

 

Situational

       

LOOP ID - 2330B

 

 

1

N2/325L

 

 

 

 

 

 

325

NM1

Other Payer Name

O

1

 

N2/325

Required

       

 

332

N3

Other Payer Address

O

1

 

 

Situational

       

 

340

N4

Other Payer City/State/ZIP Code

O

1

 

 

Situational

       

 

350

DTP

Claim Adjudication Date

O

1

 

 

Situational

       

 

355

REF

Other Payer Secondary Identification and Reference Number

O

2

 

 

Situational

       

 

355

REF

Other Payer Prior Authorization or Referral Number

O

1

 

 

Situational

       

LOOP ID - 2330C

 

 

1

N2/325L

 

 

 

 

 

 

325

NM1

Other Payer Patient Information

O

1

 

N2/325

Situational

       

 

355

REF

Other Payer Patient Identification Number

O

3

 

 

Situational

       

LOOP ID - 2330D

 

 

1

N2/325L

 

 

 

 

 

 

325

NM1

Other Payer Attending Provider

O

1

 

N2/325

Situational

       

 

355

REF

Other Payer Attending Provider Identification

O

3

 

 

Required

       

LOOP ID - 2330E

 

 

1

N2/325L

 

 

 

 

 

 

325

NM1

Other Payer Operating Provider

O

1

 

N2/325

Situational

       

 

355

REF

Other Payer Operating Provider Identification

O

3

 

 

Required

       

LOOP ID - 2330F

 

 

1

N2/325L

 

 

 

 

 

 

325

NM1

Other Payer Other Provider

O

1

 

N2/325

Situational

       

 

355

REF

Other Payer Other Provider Identification

O

3

 

 

Required

       

LOOP ID - 2330H

 

 

1

N2/325L

 

 

 

 

 

 

325

NM1

Other Payer Service Facility Provider

O

1

 

N2/325

Situational

       

 

355

REF

Other Payer Service Facility Provider Identification

O

3

 

 

Required

       

LOOP ID - 2400

 

 

999

N2/365L

 

 

 

 

 

 

365

LX

Service Line Number

O

1

 

N2/365

Required

       

 

375

SV2

Institutional Service Line

O

1

 

 

Required

       

 

420

PWK

Line Supplemental Information

O

5

 

 

Situational

       

 

455

DTP

Service Line Date

O

1

 

 

Situational

       

 

455

DTP

Assessment Date

O

1

 

 

Situational

       

LOOP ID - 2410

 

 

25

N2/493L

 

 

 

 

 

 

493

LIN

Drug Identification

O

1

 

N2/493

Situational

       

 

494

CTP

Drug Pricing

O

1

 

 

Situational

       

 

495

REF

Prescription Number

O

1

 

 

Situational

       

LOOP ID - 2420A

 

 

1

N2/500L

 

 

 

 

 

 

500

NM1

Attending Physician Name

O

1

 

N2/500

Situational

       

 

525

REF

Attending Physician Secondary Identification

O

1

 

 

Situational

       

LOOP ID - 2420B

 

 

1

N2/500L

 

 

 

 

 

 

500

NM1

Operating Physician Name

O

1

 

N2/500

Situational

       

 

525

REF

Operating Physician Secondary Identification

O

1

 

 

Situational

       

LOOP ID - 2420C

 

 

1

N2/500L

 

 

 

 

 

 

500

NM1

Other Provider Name

O

1

 

N2/500

Situational

       

 

525

REF

Other Provider Secondary Identification

O

1

 

 

Situational

       

 

555

SE

Transaction Set Trailer

M

1

 

 

Required

       

Not Defined:

 

Pos

Id

Segment Name

Req

Max Use

Repeat

Notes

Usage

 

 

 

 

 

 

GE

Functional Group Trailer

M

1

 

 

Required

       

 

 

IEA

Interchange Control Trailer

M

1

 

 

Required

       

Notes:

1/020L

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.

1/020

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.

1/020L

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.

1/020

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.

2/015L

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.

2/015

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.

2/015L

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.

2/015

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.

2/015L

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.

2/015

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.

2/250L

Loop 2310 contains information about the rendering, referring, or attending provider.

2/250

Loop 2310 contains information about the rendering, referring, or attending provider.

2/250L

Loop 2310 contains information about the rendering, referring, or attending provider.

2/250

Loop 2310 contains information about the rendering, referring, or attending provider.

2/250L

Loop 2310 contains information about the rendering, referring, or attending provider.

2/250

Loop 2310 contains information about the rendering, referring, or attending provider.

2/250L

Loop 2310 contains information about the rendering, referring, or attending provider.

2/250

Loop 2310 contains information about the rendering, referring, or attending provider.

2/290L

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.

2/290

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.

2/325L

Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

2/325

Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

2/325L

Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

2/325

Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

2/325L

Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

2/325

Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

2/325L

Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

2/325

Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

2/325L

Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

2/325

Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

2/325L

Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

2/325

Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

2/325L

Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

2/325

Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

2/365L

Loop 2400 contains Service Line information.

2/365

Loop 2400 contains Service Line information.

2/493L

Loop 2410 contains compound drug components, quantities and prices.

2/493

Loop 2410 contains compound drug components, quantities and prices.

2/500L

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.

2/500

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.

2/500L

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.

2/500

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.

2/500L

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.

2/500

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.


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