837i

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Updated:05/16/2008

Health Care Claim: Institutional
Management Systems Consulting, Inc.
VERSION: 1.0 DRAFT

Author: Skip Stein

Notes: In order to protect the security and confidentiality of electronic health information, Congress has passed The Health Insurance Portability and Accountability Act, also known as HIPAA, which was the result of efforts by the Clinton Administration and congressional healthcare reform proponents to reform healthcare in a way that would streamline industry inefficiencies, reduce paperwork, make it easier to detect and prosecute fraud and abuse and enable workers of all professions to change jobs, even if they (or family members) had pre-existing medical conditions.

837
Health Care Claim: Institutional
Functional Group=HC

This Draft Standard for Trial Use 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.

Heading:
Pos Id Segment Name Req Max Use Repeat Notes Usage
005 ST Transaction Set Header M 1
010 BHT Beginning of Hierarchical Transaction M 1
015 REF Transmission Type Identification O 1
Loop ID - 1000A 1
020 NM1 Submitter Name O 1 N1/020
045 PER Submitter EDI Contact Information O 2
Loop ID - 1000B 1
020 NM1 Receiver Name O 1 N1/020
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
003 PRV Billing/Pay-To Provider Specialty Information O 1
010 CUR Foreign Currency Information O 1
Loop ID - 2010AA 1
015 NM1 Billing Provider Name O 1 N2/015
025 N3 Billing Provider Address O 1
030 N4 Billing Provider City/State/ZIP Code O 1
035 REF Billing Provider Secondary Identification O 8
035 REF Credit/Debit Card Billing Information O 8
040 PER Billing Provider Contact Information O 2
Loop ID - 2010AB 1
015 NM1 Pay-To Provider Name O 1 N2/015
025 N3 Pay-To Provider Address O 1
030 N4 Pay-To Provider City/State/ZIP Code O 1
035 REF Pay-To Provider Secondary Identification O 5
Loop ID - 2000B >1
001 HL Subscriber Hierarchical Level M 1
005 SBR Subscriber Information O 1
007 PAT Patient Information O 1
Loop ID - 2010BA 1
015 NM1 Subscriber Name O 1 N2/015
025 N3 Subscriber Address O 1
030 N4 Subscriber City/State/ZIP Code O 1
032 DMG Subscriber Demographic Information O 1
035 REF Subscriber Secondary Identification O 4
035 REF Property and Casualty Claim Number O 1
Loop ID - 2010BB 1
015 NM1 Credit/Debit Card Account Holder Name O 1 N2/015
035 REF Credit/Debit Card Information O 2
Loop ID - 2010BC 1
015 NM1 Payer Name O 1 N2/015
025 N3 Payer Address O 1
030 N4 Payer City/State/ZIP Code O 1
035 REF Payer Secondary Identification O 3
Loop ID - 2010BD 1
015 NM1 Responsible Party Name O 1 N2/015
025 N3 Responsible Party Address O 1
030 N4 Responsible Party City/State/ZIP Code O 1
Loop ID - 2000C >1
001 HL Patient Hierarchical Level O 1
007 PAT Patient Information O 1
Loop ID - 2010CA 1
015 NM1 Patient Name O 1 N2/015
025 N3 Patient Address O 1
030 N4 Patient City/State/ZIP Code O 1
032 DMG Patient Demographic Information O 1
035 REF Patient Secondary Identification Number O 5
035 REF Property and Casualty Claim Number O 1
Loop ID - 2300 100
130 CLM Claim information O 1
135 DTP Discharge Hour O 1
135 DTP Statement Dates O 1
135 DTP Admission Date/Hour O 1
140 CL1 Institutional Claim Code O 1
155 PWK Claim Supplemental Information O 10
160 CN1 Contract Information O 1
175 AMT Payer Estimated Amount Due O 1
175 AMT Patient Estimated Amount Due O 1
175 AMT Patient Paid Amount O 1
175 AMT Credit/Debit Card Maximum Amount O 1
180 REF Adjusted Repriced Claim Number O 1
180 REF Repriced Claim Number O 1
180 REF Claim Identification Number For Clearinghouses and Other Transmission Intermedia O 1
180 REF Document Identification Code O 1
180 REF Original Reference Number (ICN/DCN) O 1
180 REF Investigational Device Exemption Number O 1
180 REF Service Authorization Exception Code O 1
180 REF Peer Review Organization (PRO) Approval Number O 1
180 REF Prior Authorization or Referral Number O 2
180 REF Medical Record Number O 1
180 REF Demonstration Project Identifier O 1
185 K3 File Information O 10
190 NTE Claim Note O 10
190 NTE Billing Note O 1
216 CR6 Home Health Care Information O 1
220 CRC Home Health Functional Limitations O 3
220 CRC Home Health Activities Permitted O 3
220 CRC Home Health Mental Status O 2
231 HI Principal, Admitting, E-Code and Patient Reason For Visit Diagnosis Information O 1
231 HI Diagnosis Related Group (DRG) Information O 1
231 HI Other Diagnosis Information O 2
231 HI Principal Procedure Information O 1
231 HI Other Procedure Information O 2
231 HI Occurrence Span Information O 2
231 HI Occurrence Information O 2
231 HI Value Information O 2
231 HI Condition Information O 2
231 HI Treatment Code Information O 2
240 QTY Claim Quantity O 4
241 HCP Claim Pricing/Repricing Information O 1
Loop ID - 2305 6
242 CR7 Home Health Care Plan Information O 1
243 HSD Health Care Services Delivery O 12
Loop ID - 2310A 1
250 NM1 Attending Physician Name O 1 N2/250
255 PRV Attending Physician Specialty Information O 1
271 REF Attending Physician Secondary Identification O 5
Loop ID - 2310B 1
250 NM1 Operating Physician Name O 1 N2/250
255 PRV Operating Physician Specialty Information O 1
271 REF Operating Physician Secondary Identification O 5
Loop ID - 2310C 1
250 NM1 Other Provider Name O 1 N2/250
255 PRV Other Provider Specialty Information O 1
271 REF Other Provider Secondary Identification O 5
Loop ID - 2310D 2
250 NM1 Referring Provider Name O 1 N2/250
255 PRV Referring Provider Specialty Information O 1
271 REF Referring Provider Secondary Identification O 5
Loop ID - 2310E 1
250 NM1 Service Facility Name O 1 N2/250
255 PRV Service Facility Specialty Information O 1
265 N3 Service Facility Address O 1
270 N4 Service Facility City/State/Zip Code O 1
271 REF Service Facility Secondary Identification O 5
Loop ID - 2320 10
290 SBR Other Subscriber Information O 1 N2/290
295 CAS Claim Level Adjustment O 5
300 AMT Payer Prior Payment O 1
300 AMT Coordination of Benefits (COB) Total Allowed Amount O 1
300 AMT Coordination of Benefits (COB) Total Submitted Charges O 1
300 AMT Diagnostic Related Group (DRG) Outlier Amount O 1
300 AMT Coordination of Benefits (COB) Total Medicare Paid Amount O 1
300 AMT Medicare Paid Amount - 100% O 1
300 AMT Medicare Paid Amount - 80% O 1
300 AMT Coordination of Benefits (COB) Medicare A Trust Fund Paid Amount O 1
300 AMT Coordination of Benefits (COB) Medicare B Trust Fund Paid Amount O 1
300 AMT Coordination of Benefits (COB) Total Non-covered Amount O 1
300 AMT Coordination of Benefits (COB) Total Denied Amount O 1
305 DMG Other Subscriber Demographic Information O 1
310 OI Other Insurance Coverage Information O 1
315 MIA Medicare Inpatient Adjudication Information O 1
320 MOA Medicare Outpatient Adjudication Information O 1
Loop ID - 2330A 1
325 NM1 Other Subscriber Name O 1 N2/325
332 N3 Other Subscriber Address O 1
340 N4 Other Subscriber City/State/ZIP Code O 1
355 REF Other Subscriber Secondary Information O 3
Loop ID - 2330B 1
325 NM1 Other Payer Name O 1 N2/325
332 N3 Other Payer Address O 1
340 N4 Other Payer City/State/ZIP Code O 1
350 DTP Claim Adjudication Date O 1
355 REF Other Payer Secondary Identification and Reference Number O 2
355 REF Other Payer Prior Authorization or Referral Number O 1
Loop ID - 2330C 1
325 NM1 Other Payer Patient Information O 1 N2/325
355 REF Other Payer Patient Identification Number O 3
Loop ID - 2330D 1
325 NM1 Other Payer Attending Provider O 1 N2/325
355 REF Other Payer Attending Provider Identification O 3
Loop ID - 2330E 1
325 NM1 Other Payer Operating Provider O 1 N2/325
355 REF Other Payer Operating Provider Identification O 3
Loop ID - 2330F 1
325 NM1 Other Payer Other Provider O 1 N2/325
355 REF Other Payer Other Provider Identification O 3
Loop ID - 2330G 2
325 NM1 Other Payer Referring Provider O 1 N2/325
355 REF Other Payer Referring Provider Identification O 3
Loop ID - 2330H 1
325 NM1 Other Payer Service Facility Provider O 1 N2/325
355 REF Other Payer Service Facility Provider Identification O 3
Loop ID - 2400 999
365 LX Service Line Number O 1 N2/365
375 SV2 Institutional Service Line O 1
385 SV4 Prescription Number O 1
420 PWK Line Supplemental Information O 5
455 DTP Service Line Date O 1
455 DTP Assessment Date O 1
475 AMT Service Tax Amount O 1
475 AMT Facility Tax Amount O 1
Loop ID - 2420A 1
500 NM1 Attending Physician Name O 1 N2/500
505 PRV Attending Physician Specialty Information O 1
525 REF Attending Physician Secondary Identification O 1
Loop ID - 2420B 1
500 NM1 Operating Physician Name O 1 N2/500
505 PRV Operating Physician Specialty Information O 1
525 REF Operating Physician Secondary Identification O 1
Loop ID - 2420C 1
500 NM1 Other Provider Name O 1 N2/500
505 PRV Other Provider Specialty Information O 1
525 REF Other Provider Secondary Identification O 1
Loop ID - 2420D 1
500 NM1 Referring Provider Name O 1 N2/500
505 PRV Other Provider Specialty Information O 1
525 REF Other Provider Secondary Identification O 1
Loop ID - 2430 25
540 SVD Service Line Adjudication Information O 1 N2/540
545 CAS Service Line Adjustment O 99
550 DTP Service Adjudication Date O 1
555 SE Transaction Set Trailer M 1

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