837

Health Care Claim: Professional

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. 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

       

 

040

PER

Billing Provider Contact Information

O

2

 

 

Situational

       

LOOP ID - 2010AB

 

 

1

N2/015L

 

 

 

 

 

 

015

NM1

Pay-to Provider Name

O

1

 

N2/015

Situational

       

 

025

N3

Pay-to Provider Address

O

1

 

 

Required

       

 

030

N4

Pay-to Provider City/State/ZIP Code

O

1

 

 

Required

       

 

035

REF

Pay-to-Provider Secondary Identification

O

5

 

 

Situational

       

LOOP ID - 2000B

 

 

>1

 

 

 

 

 

 

 

001

HL

Subscriber Hierarchical Level

M

1

 

 

Required

       

 

005

SBR

Subscriber Information

O

1

 

 

Required

       

 

007

PAT

Patient Information

O

1

 

 

Situational

       

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

 

 

Required

       

LOOP ID - 2010BB

 

 

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

       

LOOP ID - 2010BC

 

 

1

N2/015L

 

 

 

 

 

 

015

NM1

Responsible Party Name

O

1

 

N2/015

Situational

       

 

025

N3

Responsible Party Address

O

1

 

 

Required

       

 

030

N4

Responsible Party City/State/ZIP Code

O

1

 

 

Required

       

LOOP ID - 2300

 

 

100

 

 

 

 

 

 

 

130

CLM

Claim Information

O

1

 

 

Required

       

 

135

DTP

Date - Initial Treatment

O

1

 

 

Situational

       

 

135

DTP

Date - Date Last Seen

O

1

 

 

Situational

       

 

135

DTP

Date - Similar Illness/Symptom Onset

O

10

 

 

Situational

       

 

135

DTP

Date - Accident

O

10

 

 

Situational

       

 

135

DTP

Date - Last Menstrual Period

O

1

 

 

Situational

       

 

135

DTP

Date - Last X-ray

O

1

 

 

Situational

       

 

135

DTP

Date - Hearing and Vision Prescription Date

O

1

 

 

Situational

       

 

135

DTP

Date - Last Worked

O

1

 

 

Situational

       

 

135

DTP

Date - Authorized Return to Work

O

1

 

 

Situational

       

 

135

DTP

Date - Admission

O

1

 

 

Situational

       

 

155

PWK

Claim Supplemental Information

O

10

 

 

Situational

       

 

175

AMT

Patient Amount Paid

O

1

 

 

Situational

       

 

180

REF

Mammography Certification Number

O

1

 

 

Situational

       

 

180

REF

Prior Authorization or Referral Number

O

2

 

 

Situational

       

 

180

REF

Original Reference Number (ICN/DCN)

O

1

 

 

Situational

       

 

180

REF

Clinical Laboratory Improvement Amendment (CLIA) Number

O

3

 

 

Situational

       

 

180

REF

Investigational Device Exemption Number

O

1

 

 

Situational

       

 

180

REF

Ambulatory Patient Group (APG)

O

4

 

 

Situational

       

 

180

REF

Medical Record Number

O

1

 

 

Situational

       

 

190

NTE

Claim Note

O

1

 

 

Situational

       

 

195

CR1

Ambulance Transport Information

O

1

 

N2/195

Situational

       

 

200

CR2

Spinal Manipulation Service Information

O

1

 

 

Situational

       

 

220

CRC

Ambulance Certification

O

3

 

 

Situational

       

 

220

CRC

Patient Condition Information: Vision

O

3

 

 

Situational

       

 

220

CRC

EPSDT Referral

O

1

 

 

Situational

       

 

231

HI

Health Care Diagnosis Code

O

1

 

 

Situational

       

LOOP ID - 2305

 

 

6

 

 

 

 

 

 

 

242

CR7

Home Health Care Plan Information

O

1

 

 

Situational

       

 

243

HSD

Health Care Services Delivery

O

3

 

 

Situational

       

LOOP ID - 2310B

 

 

1

N2/250L

 

 

 

 

 

 

250

NM1

Rendering Provider Name

O

1

 

N2/250

Situational

       

 

255

PRV

Rendering Provider Specialty Information

O

1

 

 

Situational

       

 

271

REF

Rendering Provider Secondary Identification

O

5

 

 

Situational

       

LOOP ID - 2400

 

 

50

N2/365L

 

 

 

 

 

 

365

LX

Service Line

O

1

 

N2/365

Required

       

 

370

SV1

Professional Service

O

1

 

 

Required

       

 

400

SV5

Durable Medical Equipment Service

O

1

 

 

Situational

       

 

425

CR1

Ambulance Transport Information

O

1

 

N2/425

Situational

       

 

430

CR2

Spinal Manipulation Service Information

O

5

 

 

Situational

       

 

435

CR3

Durable Medical Equipment Certification

O

1

 

 

Situational

       

 

445

CR5

Home Oxygen Therapy Information

O

1

 

 

Situational

       

 

450

CRC

Ambulance Certification

O

3

 

 

Situational

       

 

450

CRC

DMERC Condition Indicator

O

2

 

 

Situational

       

 

455

DTP

Date - Service Date

O

1

 

 

Required

       

 

455

DTP

Date - Certification Revision Date

O

1

 

 

Situational

       

 

455

DTP

Date - Begin Therapy Date

O

1

 

 

Situational

       

 

455

DTP

Date - Last Certification Date

O

1

 

 

Situational

       

 

455

DTP

Date - Date Last Seen

O

1

 

 

Situational

       

 

455

DTP

Date - Test

O

2

 

 

Situational

       

 

455

DTP

Date - Oxygen Saturation/Arterial Blood Gas Test

O

3

 

 

Situational

       

 

455

DTP

Date - Shipped

O

1

 

 

Situational

       

 

455

DTP

Date - Onset of Current Symptom/Illness

O

1

 

 

Situational

       

 

455

DTP

Date - Last X-ray

O

1

 

 

Situational

       

 

455

DTP

Date - Acute Manifestation

O

1

 

 

Situational

       

 

455

DTP

Date - Initial Treatment

O

1

 

 

Situational

       

 

455

DTP

Date - Similar Illness/Symptom Onset

O

1

 

 

Situational

       

 

462

MEA

Test Result

O

20

 

 

Situational

       

 

470

REF

Line Item Control Number

O

1

 

 

Situational

       

 

470

REF

Mammography Certification Number

O

1

 

 

Situational

       

 

470

REF

Clinical Laboratory Improvement Amendment (CLIA) Identification

O

1

 

 

Situational

       

 

470

REF

Immunization Batch Number

O

1

 

 

Situational

       

 

470

REF

Oxygen Flow Rate

O

1

 

 

Situational

       

 

470

REF

Universal Product Number (UPN)

O

1

 

 

Situational

       

 

485

NTE

Line Note

O

1

 

 

Situational

       

 

491

HSD

Health Care Services Delivery

O

1

 

 

Situational

       

LOOP ID - 2420A

 

 

1

N2/500L

 

 

 

 

 

 

500

NM1

Rendering Provider Name

O

1

 

N2/500

Situational

       

 

505

PRV

Rendering Provider Specialty Information

O

1

 

 

Situational

       

 

525

REF

Rendering Provider Secondary Identification

O

5

 

 

Situational

       

LOOP ID - 2430

 

 

25

N2/540L

 

 

 

 

 

 

540

SVD

Line Adjudication Information

O

1

 

N2/540

Situational

       

 

545

CAS

Line Adjustment

O

99

 

 

Situational

       

 

550

DTP

Line Adjudication Date

O

1

 

 

Required

       

LOOP ID - 2440

 

 

5

N2/551L

 

 

 

 

 

 

551

LQ

Form Identification Code

O

1

 

N2/551

Situational

       

 

552

FRM

Supporting Documentation

O

99

 

N2/552

Required

       

 

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.

2/015L

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.

2/195

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.

2/250L

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

2/250

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

2/365L

Loop 2400 contains Service Line information.

2/365

Loop 2400 contains Service Line information.

2/425

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.

2/500L

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.

2/540L

SVD01 identifies the payer which adjudicated the corresponding service line and must match DE 67 in the NM109 position 325 for the payer.

2/540

SVD01 identifies the payer which adjudicated the corresponding service line and must match DE 67 in the NM109 position 325 for the payer.

2/551L

Loop 2440 provides certificate of medical necessity information for the procedure identified in SV101 in position 2/3700.

2/551

Loop 2440 provides certificate of medical necessity information for the procedure identified in SV101 in position 2/3700.

2/552

RM segment provides question numbers and responses for the questions on the medical necessity information form identified in LQ position 551.


1. The 837 transaction is designed to transmit one or more claims for each billing provider. The hierarchy of the looping structure is billing provider, subscriber, patient, claim level, and claim service line level. Billing providers who sort claims using this hierarchy will use the 837 more efficiently because information that applies to all lower levels in the hierarchy will not have to be repeated within the transaction.
2. This standard is also recommended for the submission of similar data within a pre-paid managed care context. Referred to as capitated encounters, this data usually does not result in a payment, though it is possible to submit a “mixed” claim that includes both pre-paid and request for payment services. This standard will allow for the submission of data from providers of health care products and services to a Managed Care Organization or other payer. This standard may also be used by payers to share data with plan sponsors, employers, regulatory entities and Community Health Information Networks.


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