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Updated:09/19/2008

HIPAA 837 Health Care Claim: Professional
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: Professional
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
025 N2 Additional Submitter Name Information O 1
045 PER Submitter EDI Contact Information O 2
Loop ID - 1000B 1
020 NM1 Receiver Name O 1 N1/020
025 N2 Receiver Additional Name Information O 1
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
020 N2 Additional Billing Provider Name Information O 1
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
020 N2 Additional Pay-to Provider Name Information O 1
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
020 N2 Additional Subscriber Name Information O 1
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 Payer Name O 1 N2/015
020 N2 Additional Payer Name Information O 1
025 N3 Payer Address O 1
030 N4 Payer City/State/ZIP Code O 1
035 REF Payer Secondary Identification O 3
Loop ID - 2010BC 1
015 NM1 Responsible Party Name O 1 N2/015
020 N2 Additional Responsible Party Name Information O 1
025 N3 Responsible Party Address O 1
030 N4 Responsible Party City/State/ZIP Code O 1
Loop ID - 2010BD 1
015 NM1 Credit/Debit Card Holder Name O 1 N2/015
020 N2 Additional Credit/Debit Card Holder Name Information O 1
035 REF Credit/Debit Card Information O 2
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
020 N2 Additional Patient Name Information O 1
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 O 5
035 REF Property and Casualty Claim Number O 1
Loop ID - 2300 100
130 CLM Claim Information O 1
135 DTP Date - Order Date O 1
135 DTP Date - Initial Treatment O 1
135 DTP Date - Referral Date O 1
135 DTP Date - Date Last Seen O 1
135 DTP Date - Onset of Current Illness/Symptom O 1
135 DTP Date - Acute Manifestation O 5
135 DTP Date - Similar Illness/Symptom Onset O 10
135 DTP Date - Accident O 10
135 DTP Date - Last Menstrual Period O 1
135 DTP Date - Last X-ray O 1
135 DTP Date - Estimated Date of Birth O 1
135 DTP Date - Hearing and Vision Prescription Date O 1
135 DTP Date - Disability Begin O 5
135 DTP Date - Disability End O 5
135 DTP Date - Last Worked O 1
135 DTP Date - Authorized Return to Work O 1
135 DTP Date - Admission O 1
135 DTP Date - Discharge O 1
135 DTP Date - Assumed and Relinquished Care Dates O 2
155 PWK Claim Supplemental Information O 10
160 CN1 Contract Information O 1
175 AMT Credit/Debit Card Maximum Amount O 1
175 AMT Patient Amount Paid O 1
175 AMT Total Purchased Service Amount O 1
180 REF Service Authorization Exception Code O 1
180 REF Mandatory Medicare (Section 4081) Crossover Indicator O 1
180 REF Mammography Certification Number O 1
180 REF Prior Authorization or Referral Number O 2
180 REF Original Reference Number (ICN/DCN) O 1
180 REF Clinical Laboratory Improvement Amendment (CLIA) Number O 3
180 REF Repriced Claim Number O 1
180 REF Adjusted Repriced Claim Number O 1
180 REF Investigational Device Exemption Number O 1
180 REF Claim Identification Number for Clearing Houses and Other Transmission Intermedi O 1
180 REF Ambulatory Patient Group (APG) O 4
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 1
195 CR1 Ambulance Transport Information O 1 N2/195
200 CR2 Spinal Manipulation Service Information O 1
220 CRC Ambulance Certification O 3
220 CRC Patient Condition Information: Vision O 3
220 CRC Homebound Indicator O 1
231 HI Health Care Diagnosis Code O 1
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 3
Loop ID - 2310A 2
250 NM1 Referring Provider Name O 1 N2/250
255 PRV Referring Provider Specialty Information O 1
260 N2 Additional Referring Provider Name Information O 1
271 REF Referring Provider Secondary Identification O 5
Loop ID - 2310B 1
250 NM1 Rendering Provider Name O 1 N2/250
255 PRV Rendering Provider Specialty Information O 1
260 N2 Additional Rendering Provider Name Information O 1
271 REF Rendering Provider Secondary Identification O 5
Loop ID - 2310C 1
250 NM1 Purchased Service Provider Name O 1 N2/250
271 REF Purchased Service Provider Secondary Identification O 5
Loop ID - 2310D 1
250 NM1 Service Facility Location O 1 N2/250
260 N2 Additional Service Facility Location Name Information O 1
265 N3 Service Facility Location Address O 1
270 N4 Service Facility Location City/State/ZIP O 1
271 REF Service Facility Location Secondary Identification O 5
Loop ID - 2310E 1
250 NM1 Supervising Provider Name O 1 N2/250
260 N2 Additional Supervising Provider Name Information O 1
271 REF Supervising Provider Secondary Identification O 5
Loop ID - 2320 10
290 SBR Other Subscriber Information O 1 N2/290
295 CAS Claim Level Adjustments O 5
300 AMT Coordination of Benefits (COB) Payer Paid Amount O 1
300 AMT Coordination of Benefits (COB) Approved Amount O 1
300 AMT Coordination of Benefits (COB) Allowed Amount O 1
300 AMT Coordination of Benefits (COB) Patient Responsibility Amount O 1
300 AMT Coordination of Benefits (COB) Covered Amount O 1
300 AMT Coordination of Benefits (COB) Discount Amount O 1
300 AMT Coordination of Benefits (COB) Per Day Limit Amount O 1
300 AMT Coordination of Benefits (COB) Patient Paid Amount O 1
300 AMT Coordination of Benefits (COB) Tax Amount O 1
300 AMT Coordination of Benefits (COB) Total Claim Before Taxes Amount O 1
305 DMG Subscriber Demographic Information O 1
310 OI Other Insurance Coverage Information O 1
320 MOA Medicare Outpatient Adjudication Information O 1
Loop ID - 2330A 1
325 NM1 Other Subscriber Name O 1 N2/325
330 N2 Additional Other Subscriber Name Information O 1
332 N3 Other Subscriber Address O 1
340 N4 Other Subscriber City/State/ZIP Code O 1
355 REF Other Subscriber Secondary Identification O 3
Loop ID - 2330B 1
325 NM1 Other Payer Name O 1 N2/325
330 N2 Additional Other Payer Name Information O 1
345 PER Additional Other Payer Name Information O 2
350 DTP Claim Adjudication Date O 1
355 REF Other Payer Secondary Identifier O 2
355 REF Other Payer Prior Authorization or Referral Number O 2
355 REF Other Payer Claim Adjustment Indicator O 2
Loop ID - 2330C 1
325 NM1 Other Payer Patient Information O 1 N2/325
355 REF Other Payer Patient Identification O 3
Loop ID - 2330D 2
325 NM1 Other Payer Referring Provider O 1 N2/325
355 REF Other Payer Referring Provider Identification O 3
Loop ID - 2330E 1
325 NM1 Other Payer Rendering Provider O 1 N2/325
355 REF Other Payer Rendering Provider Secondary Identification O 3
Loop ID - 2330F 1
325 NM1 Other Payer Purchased Service Provider O 1 N2/325
355 REF Other Payer Purchased Service Provider Identification O 3
Loop ID - 2330G 1
325 NM1 Other Payer Service Facility Location O 1 N2/325
355 REF Other Payer Service Facility Location Identification O 3
Loop ID - 2330H 1
325 NM1 Other Payer Supervising Provider O 1 N2/325
355 REF Other Payer Supervising Provider Identification O 3
Loop ID - 2400 50
365 LX Service Line O 1 N2/365
370 SV1 Professional Service O 1
385 SV4 Prescription Number O 1
420 PWK DMERC CMN Indicator O 1
425 CR1 Ambulance Transport Information O 1 N2/425
430 CR2 Spinal Manipulation Service Information O 5
435 CR3 Durable Medical Equipment Certification O 1
445 CR5 Home Oxygen Therapy Information O 1
450 CRC Ambulance Certification O 3
450 CRC Hospice Employee Indicator O 1
450 CRC DMERC Condition Indicator O 2
455 DTP Date - Service Date O 1
455 DTP Date - Certification Revision Date O 1
455 DTP Date - Referral Date O 1
455 DTP Date - Begin Therapy Date O 1
455 DTP Date - Last Certification Date O 1
455 DTP Date - Order Date O 1
455 DTP Date - Date Last Seen O 1
455 DTP Date - Test O 2
455 DTP Date - Oxygen Saturation/Arterial Blood Gas Test O 3