837Health Care Claim

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 standard can be used to submit health care claim billing information 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. 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. 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.

  • ST
    Transaction Set Header
    M必须(Mandatory)
    Repeat 1

    To indicate the start of a transaction set and to assign a control number

  • BGN
    Beginning Segment
    O可选(Optional)
    Repeat 1

    To indicate the beginning of a transaction set.

  • REF
    Reference Numbers
    O可选(Optional)
    Repeat 3

    To specify identifying numbers.

  • NM1Loop1Individual or Organizational Name LOOPO可选(Optional)Repeat 10
    NM1N2N3N4REFPER
    • NM1
      Individual or Organizational Name
      M必须(Mandatory)
      Repeat 1

      To supply the full name of an individual or organizational entity

    • N2
      Additional Name Information
      O可选(Optional)
      Repeat 2

      To specify additional names or those longer than 35 characters in length

    • N3
      Address Information
      O可选(Optional)
      Repeat 2

      To specify the location of the named party

    • N4
      Geographic Location
      O可选(Optional)
      Repeat 1

      To specify the geographic place of the named party

    • REF
      Reference Numbers
      O可选(Optional)
      Repeat 2

      To specify identifying numbers.

    • PER
      Administrative Communications Contact
      O可选(Optional)
      Repeat 2

      To identify a person or office to whom administrative communications should be directed

  • PRVLoop1Provider Information LOOPM必须(Mandatory)Repeat 100
    PRVCURNM1Loop2SBRLoop1
    • PRV
      Provider Information
      M必须(Mandatory)
      Repeat 1

      To specify the identifying characteristics of a provider

    • CUR
      Currency
      O可选(Optional)
      Repeat 1

      To specify the currency (dollars, pounds, francs, etc.) used in a transaction

    • NM1Loop2Individual or Organizational Name LOOPO可选(Optional)Repeat 2
      NM1N2N3N4REFPER
      • NM1
        Individual or Organizational Name
        M必须(Mandatory)
        Repeat 1

        To supply the full name of an individual or organizational entity

      • N2
        Additional Name Information
        O可选(Optional)
        Repeat 2

        To specify additional names or those longer than 35 characters in length

      • N3
        Address Information
        O可选(Optional)
        Repeat 2

        To specify the location of the named party

      • N4
        Geographic Location
        O可选(Optional)
        Repeat 1

        To specify the geographic place of the named party

      • REF
        Reference Numbers
        O可选(Optional)
        Repeat 20

        To specify identifying numbers.

      • PER
        Administrative Communications Contact
        O可选(Optional)
        Repeat 2

        To identify a person or office to whom administrative communications should be directed

    • SBRLoop1Subscriber Information LOOPM必须(Mandatory)Repeat 99999
      SBRDTPNM1Loop3PATLoop1
      • SBR
        Subscriber Information
        M必须(Mandatory)
        Repeat 1

        To record claim information specific to the primary insured and the insurance carrier for that insured

      • DTP
        Date or Time or Period
        O可选(Optional)
        Repeat 5

        To specify any or all of a date, a time, or a time period

      • NM1Loop3Individual or Organizational Name LOOPO可选(Optional)Repeat 10
        NM1N2N3N4DMGPERREF
        • NM1
          Individual or Organizational Name
          M必须(Mandatory)
          Repeat 1

          To supply the full name of an individual or organizational entity

        • N2
          Additional Name Information
          O可选(Optional)
          Repeat 2

          To specify additional names or those longer than 35 characters in length

        • N3
          Address Information
          O可选(Optional)
          Repeat 2

          To specify the location of the named party

        • N4
          Geographic Location
          O可选(Optional)
          Repeat 1

          To specify the geographic place of the named party

        • DMG
          Demographic Information
          O可选(Optional)
          Repeat 1

          To supply demographic information

        • PER
          Administrative Communications Contact
          O可选(Optional)
          Repeat 2

          To identify a person or office to whom administrative communications should be directed

        • REF
          Reference Numbers
          O可选(Optional)
          Repeat 5

          To specify identifying numbers.

      • PATLoop1Patient Information LOOPM必须(Mandatory)Repeat 99
        PATNM1Loop4CLMLoop1
        • PAT
          Patient Information
          M必须(Mandatory)
          Repeat 1

          To supply patient information

        • NM1Loop4Individual or Organizational Name LOOPO可选(Optional)Repeat 10
          NM1N2N3N4DMGPERREF
          • NM1
            Individual or Organizational Name
            M必须(Mandatory)
            Repeat 1

            To supply the full name of an individual or organizational entity

          • N2
            Additional Name Information
            O可选(Optional)
            Repeat 2

            To specify additional names or those longer than 35 characters in length

          • N3
            Address Information
            O可选(Optional)
            Repeat 2

            To specify the location of the named party

          • N4
            Geographic Location
            O可选(Optional)
            Repeat 1

            To specify the geographic place of the named party

          • DMG
            Demographic Information
            O可选(Optional)
            Repeat 1

            To supply demographic information

          • PER
            Administrative Communications Contact
            O可选(Optional)
            Repeat 2

            To identify a person or office to whom administrative communications should be directed

          • REF
            Reference Numbers
            O可选(Optional)
            Repeat 5

            To specify identifying numbers.

        • CLMLoop1Health Claim LOOPM必须(Mandatory)Repeat 100
          CLMDTPCL1DN1DN2PWKCN1DSBURAMTREFK3NTECR1CR2CR3CR4CR5CRCPCAM1CD2QTYLSLoop1LXLoop1LSLoop3
          • CLM
            Health Claim
            M必须(Mandatory)
            Repeat 1

            To specify basic data about the claim

          • DTP
            Date or Time or Period
            O可选(Optional)
            Repeat 40

            To specify any or all of a date, a time, or a time period

          • CL1
            Claim Codes
            O可选(Optional)
            Repeat 1

            To supply information specific to hospital claims

          • DN1
            Orthodontic Information
            O可选(Optional)
            Repeat 1

            To supply orthodontic information

          • DN2
            Tooth Summary
            O可选(Optional)
            Repeat 35

            To specify the status of individual teeth

          • PWK
            Paperwork
            O可选(Optional)
            Repeat 10

            To identify the type and transmission of paperwork or supporting information

          • CN1
            Contract Information
            O可选(Optional)
            Repeat 1

            To specify basic data about the contract

          • DSB
            Disability Information
            O可选(Optional)
            Repeat 1

            To supply disability information

          • UR
            Peer Review Organization or Utilization Review
            O可选(Optional)
            Repeat 1

            To specify the results of the utilization review

          • AMT
            Monetary Amount
            O可选(Optional)
            Repeat 40

            To indicate the total monetary amount.

          • REF
            Reference Numbers
            O可选(Optional)
            Repeat 10

            To specify identifying numbers.

          • K3
            File Information
            O可选(Optional)
            Repeat 10

            To transmit a fixed format record

          • NTE
            Note/Special Instruction
            O可选(Optional)
            Repeat 4

            To transmit information in a free-form format, if necessary, for comment or special instruction

          • CR1
            Ambulance Certification
            O可选(Optional)
            Repeat 1

            To supply information related to the ambulance service rendered to a patient

          • CR2
            Chiropractic Certification
            O可选(Optional)
            Repeat 1

            To supply information to the chiropractic service rendered to a patient

          • CR3
            Durable Medical Equipment Certification
            O可选(Optional)
            Repeat 1

            To supply information regarding a physician's certification for durable medical equipment

          • CR4
            Enteral or Parenteral Therapy Certification
            O可选(Optional)
            Repeat 3

            To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy

          • CR5
            Oxygen Therapy Certification
            O可选(Optional)
            Repeat 1

            To supply information regarding certification of medical necessity for home oxygen therapy

          • CRC
            Certification Conditions
            O可选(Optional)
            Repeat 3

            To supply information on the conditions related to a certification

          • PC
            Procedure Codes
            O可选(Optional)
            Repeat 25

            To specify a procedure code and the date associated with it

          • AM1
            Informational Values
            O可选(Optional)
            Repeat 25

            To specify a code and the amount, quantity associated with it, or both

          • CD2
            Multi-Valued Characteristics
            O可选(Optional)
            Repeat 30

            To provide characteristics that may have multiple values

          • QTY
            Quantity
            O可选(Optional)
            Repeat 10

            To specify quantity information.

          • LSLoop1Loop Header LOOPO可选(Optional)Repeat 1
            LSNM1Loop5LE
            • LS
              Loop Header
              M必须(Mandatory)
              Repeat 1

              To indicate that the next segment begins a loop

            • NM1Loop5Individual or Organizational Name LOOPO可选(Optional)Repeat 9
              NM1PRVN2N3N4PER
              • NM1
                Individual or Organizational Name
                M必须(Mandatory)
                Repeat 1

                To supply the full name of an individual or organizational entity

              • PRV
                Provider Information
                O可选(Optional)
                Repeat 1

                To specify the identifying characteristics of a provider

              • N2
                Additional Name Information
                O可选(Optional)
                Repeat 2

                To specify additional names or those longer than 35 characters in length

              • N3
                Address Information
                O可选(Optional)
                Repeat 2

                To specify the location of the named party

              • N4
                Geographic Location
                O可选(Optional)
                Repeat 1

                To specify the geographic place of the named party

              • PER
                Administrative Communications Contact
                O可选(Optional)
                Repeat 2

                To identify a person or office to whom administrative communications should be directed

            • LE
              Loop Trailer
              M必须(Mandatory)
              Repeat 1

              To indicate that the loop immediately preceding this segment is complete

          • LXLoop1Assigned Number LOOPO可选(Optional)Repeat 10000
            LXSV1SV2SV3SV4LINLoop1SV5SV6SV7CD2PWKCR1CR2CR3CR4CR5CRCDTPQTYCN1REFAMTK3NTEPS1LSLoop2
            • LX
              Assigned Number
              M必须(Mandatory)
              Repeat 1

              To reference a line number in a transaction set.

            • SV1
              Professional Service
              O可选(Optional)
              Repeat 1

              To specify the claim service detail for a Health Care professional

            • SV2
              Institutional Service
              O可选(Optional)
              Repeat 1

              To specify the claim service detail for a Health Care institution

            • SV3
              Dental Service
              O可选(Optional)
              Repeat 1

              To specify the claim service detail for dental work

            • SV4
              Drug Service
              O可选(Optional)
              Repeat 1

              To specify the claim service detail for prescription drugs

            • LINLoop1Item Identification LOOPO可选(Optional)Repeat 10
              LINCTP
              • LIN
                Item Identification
                M必须(Mandatory)
                Repeat 1

                To specify basic item identification data.

              • CTP
                Pricing Information
                O可选(Optional)
                Repeat 1

                To specify pricing information

            • SV5
              Durable Medical Equipment Service
              O可选(Optional)
              Repeat 1

              To specify the claim service detail for durable medical equipment

            • SV6
              Anesthesia Service
              O可选(Optional)
              Repeat 1

              To specify the claim service detail for anesthesia

            • SV7
              Drug Adjudication
              O可选(Optional)
              Repeat 1

              To specify the claim service detail for drug services that have been adjudicated

            • CD2
              Multi-Valued Characteristics
              O可选(Optional)
              Repeat 5

              To provide characteristics that may have multiple values

            • PWK
              Paperwork
              O可选(Optional)
              Repeat 10

              To identify the type and transmission of paperwork or supporting information

            • CR1
              Ambulance Certification
              O可选(Optional)
              Repeat 1

              To supply information related to the ambulance service rendered to a patient

            • CR2
              Chiropractic Certification
              O可选(Optional)
              Repeat 5

              To supply information to the chiropractic service rendered to a patient

            • CR3
              Durable Medical Equipment Certification
              O可选(Optional)
              Repeat 1

              To supply information regarding a physician's certification for durable medical equipment

            • CR4
              Enteral or Parenteral Therapy Certification
              O可选(Optional)
              Repeat 3

              To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy

            • CR5
              Oxygen Therapy Certification
              O可选(Optional)
              Repeat 1

              To supply information regarding certification of medical necessity for home oxygen therapy

            • CRC
              Certification Conditions
              O可选(Optional)
              Repeat 3

              To supply information on the conditions related to a certification

            • DTP
              Date or Time or Period
              O可选(Optional)
              Repeat 15

              To specify any or all of a date, a time, or a time period

            • QTY
              Quantity
              O可选(Optional)
              Repeat 5

              To specify quantity information.

            • CN1
              Contract Information
              O可选(Optional)
              Repeat 1

              To specify basic data about the contract

            • REF
              Reference Numbers
              O可选(Optional)
              Repeat 10

              To specify identifying numbers.

            • AMT
              Monetary Amount
              O可选(Optional)
              Repeat 15

              To indicate the total monetary amount.

            • K3
              File Information
              O可选(Optional)
              Repeat 10

              To transmit a fixed format record

            • NTE
              Note/Special Instruction
              O可选(Optional)
              Repeat 10

              To transmit information in a free-form format, if necessary, for comment or special instruction

            • PS1
              Purchase Service
              O可选(Optional)
              Repeat 1

              To specify the information about services that are purchased

            • LSLoop2Loop Header LOOPO可选(Optional)Repeat 1
              LSNM1Loop6LE
              • LS
                Loop Header
                M必须(Mandatory)
                Repeat 1

                To indicate that the next segment begins a loop

              • NM1Loop6Individual or Organizational Name LOOPO可选(Optional)Repeat 10
                NM1PRVN2N3N4PER
                • NM1
                  Individual or Organizational Name
                  M必须(Mandatory)
                  Repeat 1

                  To supply the full name of an individual or organizational entity

                • PRV
                  Provider Information
                  O可选(Optional)
                  Repeat 1

                  To specify the identifying characteristics of a provider

                • N2
                  Additional Name Information
                  O可选(Optional)
                  Repeat 2

                  To specify additional names or those longer than 35 characters in length

                • N3
                  Address Information
                  O可选(Optional)
                  Repeat 2

                  To specify the location of the named party

                • N4
                  Geographic Location
                  O可选(Optional)
                  Repeat 1

                  To specify the geographic place of the named party

                • PER
                  Administrative Communications Contact
                  O可选(Optional)
                  Repeat 2

                  To identify a person or office to whom administrative communications should be directed

              • LE
                Loop Trailer
                M必须(Mandatory)
                Repeat 1

                To indicate that the loop immediately preceding this segment is complete

          • LSLoop3Loop Header LOOPO可选(Optional)Repeat 1
            LSNM1Loop7LE
            • LS
              Loop Header
              M必须(Mandatory)
              Repeat 1

              To indicate that the next segment begins a loop

            • NM1Loop7Individual or Organizational Name LOOPO可选(Optional)Repeat 10
              NM1N2N3N4PERSBRCA1AMTDMGDTPREF
              • NM1
                Individual or Organizational Name
                M必须(Mandatory)
                Repeat 1

                To supply the full name of an individual or organizational entity

              • N2
                Additional Name Information
                O可选(Optional)
                Repeat 2

                To specify additional names or those longer than 35 characters in length

              • N3
                Address Information
                O可选(Optional)
                Repeat 2

                To specify the location of the named party

              • N4
                Geographic Location
                O可选(Optional)
                Repeat 1

                To specify the geographic place of the named party

              • PER
                Administrative Communications Contact
                O可选(Optional)
                Repeat 1

                To identify a person or office to whom administrative communications should be directed

              • SBR
                Subscriber Information
                O可选(Optional)
                Repeat 1

                To record claim information specific to the primary insured and the insurance carrier for that insured

              • CA1
                Claim Adjudication
                O可选(Optional)
                Repeat 1

                To specify the adjudication codes for a claim service item

              • AMT
                Monetary Amount
                O可选(Optional)
                Repeat 15

                To indicate the total monetary amount.

              • DMG
                Demographic Information
                O可选(Optional)
                Repeat 1

                To supply demographic information

              • DTP
                Date or Time or Period
                O可选(Optional)
                Repeat 2

                To specify any or all of a date, a time, or a time period

              • REF
                Reference Numbers
                O可选(Optional)
                Repeat 3

                To specify identifying numbers.

            • LE
              Loop Trailer
              M必须(Mandatory)
              Repeat 1

              To indicate that the loop immediately preceding this segment is complete

  • SE
    Transaction Set Trailer
    M必须(Mandatory)
    Repeat 1

    To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments).

Segment
X12 EDI Release 00303
To indicate the start of a transaction set and to assign a control number
Elements
  • ST01143Transaction Set Identifier Code
    ID
    M必须(Mandatory)
    Min 3 / Max 3

    Code uniquely identifying a Transaction Set.

    Codes (320)
  • ST02329Transaction Set Control Number
    AN
    M必须(Mandatory)
    Min 4 / Max 9

    Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

  • ST031705Implementation Convention Preference
    AN
    O可选(Optional)
    Min 1 / Max 9