837Health Care Claim

This X12 Transaction Set 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.

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

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

  • BHT
    Beginning of Hierarchical Transaction
    M必须(Mandatory)
    Repeat 1

    To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time

  • REF
    Reference Information
    O可选(Optional)
    Repeat 3

    To specify identifying information

  • 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

    • N3
      Party Location
      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 Information
      O可选(Optional)
      Repeat 2

      To specify identifying information

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

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

  • HLLoop1Hierarchical Level LOOPM必须(Mandatory)Repeat > 1
    HLPRVSBRPATDTPCURNM1Loop2CLMLoop1
    • HL
      Hierarchical Level
      M必须(Mandatory)
      Repeat 1

      To identify dependencies among and the content of hierarchically related groups of data segments

    • PRV
      Provider Information
      O可选(Optional)
      Repeat 1

      To specify the identifying characteristics of a provider

    • SBR
      Subscriber Information
      O可选(Optional)
      Repeat 1

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

    • PAT
      Patient Information
      O可选(Optional)
      Repeat 1

      To supply patient information

    • 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

    • 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 10
      NM1N2N3N4DMGREFPER
      • 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

      • N3
        Party Location
        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

      • REF
        Reference Information
        O可选(Optional)
        Repeat 20

        To specify identifying information

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

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

    • CLMLoop1Health Claim LOOPO可选(Optional)Repeat 100
      CLMDTPCL1DN1DN2PWKCN1DSBURAMTREFK3NTECR1CR2CR3CR4CR5CR6CR8CRCHIQTYHCPCR7Loop1NM1Loop3SBRLoop1LXLoop1
      • 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 150

        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 or transmission or both of paperwork or supporting information

      • CN1
        Contract Information
        O可选(Optional)
        Repeat 1

        To specify basic data about the contract or contract line item

      • 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 Information
        O可选(Optional)
        Repeat 40

        To indicate the total monetary amount

      • REF
        Reference Information
        O可选(Optional)
        Repeat 30

        To specify identifying information

      • K3
        File Information
        O可选(Optional)
        Repeat 10

        To transmit a fixed-format record or matrix contents

      • NTE
        Note/Special Instruction
        O可选(Optional)
        Repeat 20

        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 related 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

      • CR6
        Home Health Care Certification
        O可选(Optional)
        Repeat 1

        To supply information related to the certification of a home health care patient

      • CR8
        Pacemaker Certification
        O可选(Optional)
        Repeat 9

        To supply information related to Pacemaker registry

      • CRC
        Conditions Indicator
        O可选(Optional)
        Repeat 100

        To supply information on conditions

      • HI
        Health Care Information Codes
        O可选(Optional)
        Repeat 25

        To supply information related to the delivery of health care

      • QTY
        Quantity Information
        O可选(Optional)
        Repeat 10

        To specify quantity information

      • HCP
        Health Care Pricing
        O可选(Optional)
        Repeat 1

        To specify pricing or repricing information about a health care claim or line item

      • CR7Loop1Home Health Treatment Plan Certification LOOPO可选(Optional)Repeat 6
        CR7HSD
        • CR7
          Home Health Treatment Plan Certification
          M必须(Mandatory)
          Repeat 1

          To supply information related to the home health care plan of treatment and services

        • HSD
          Health Care Services Delivery
          O可选(Optional)
          Repeat 12

          To specify the delivery pattern of health care services

      • NM1Loop3Individual or Organizational Name LOOPO可选(Optional)Repeat 9
        NM1PRVN2N3N4REFPER
        • 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

        • N3
          Party Location
          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 Information
          O可选(Optional)
          Repeat 20

          To specify identifying information

        • 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 LOOPO可选(Optional)Repeat 10
        SBRCASAMTDMGOIMIAMOANM1Loop4
        • SBR
          Subscriber Information
          M必须(Mandatory)
          Repeat 1

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

        • CAS
          Claims Adjustment
          O可选(Optional)
          Repeat 99

          To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

        • AMT
          Monetary Amount Information
          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

        • OI
          Other Health Insurance Information
          O可选(Optional)
          Repeat 1

          To specify information associated with other health insurance coverage

        • MIA
          Medicare Inpatient Adjudication
          O可选(Optional)
          Repeat 1

          To provide claim-level data related to the adjudication of Medicare inpatient claims

        • MOA
          Medicare Outpatient Adjudication
          O可选(Optional)
          Repeat 1

          To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting

        • NM1Loop4Individual or Organizational Name LOOPO可选(Optional)Repeat 10
          NM1N2N3N4PERDTPREF
          • 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

          • N3
            Party Location
            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

          • DTP
            Date or Time or Period
            O可选(Optional)
            Repeat 9

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

          • REF
            Reference Information
            O可选(Optional)
            Repeat > 1

            To specify identifying information

      • LXLoop1Transaction Set Line Number LOOPO可选(Optional)Repeat > 1
        LXSV1SV2SV3TOOSV4SV5SV6SV7HIPWKCR1CR2CR3CR4CR5CRCDTPQTYMEACN1REFAMTK3NTEPS1IMMHSDHCPLINLoop1NM1Loop5SVDLoop1LQLoop1
        • LX
          Transaction Set Line 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 service line item detail for a health care professional

        • SV2
          Institutional Service
          O可选(Optional)
          Repeat 1

          To specify the service line item detail for a health care institution

        • SV3
          Dental Service
          O可选(Optional)
          Repeat 1

          To specify the service line item detail for dental work

        • TOO
          Tooth Identification
          O可选(Optional)
          Repeat 32

          To identify a tooth by number and, if applicable, one or more tooth surfaces

        • SV4
          Drug Service
          O可选(Optional)
          Repeat 1

          To specify the claim service detail for prescription drugs

        • 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

        • HI
          Health Care Information Codes
          O可选(Optional)
          Repeat 25

          To supply information related to the delivery of health care

        • PWK
          Paperwork
          O可选(Optional)
          Repeat 10

          To identify the type or transmission or both 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 related 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
          Conditions Indicator
          O可选(Optional)
          Repeat 3

          To supply information on conditions

        • 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 Information
          O可选(Optional)
          Repeat 5

          To specify quantity information

        • MEA
          Measurements
          O可选(Optional)
          Repeat 20

          To specify physical measurements or counts, including dimensions, tolerances, variances, and weights (See Figures Appendix for example of use of C001)

        • CN1
          Contract Information
          O可选(Optional)
          Repeat 1

          To specify basic data about the contract or contract line item

        • REF
          Reference Information
          O可选(Optional)
          Repeat 30

          To specify identifying information

        • AMT
          Monetary Amount Information
          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 or matrix contents

        • 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

        • IMM
          Immunization Status
          O可选(Optional)
          Repeat > 1

          To provide the receiving school district or postsecondary institution with a notice of the immunization status of the student

        • HSD
          Health Care Services Delivery
          O可选(Optional)
          Repeat 1

          To specify the delivery pattern of health care services

        • HCP
          Health Care Pricing
          O可选(Optional)
          Repeat 1

          To specify pricing or repricing information about a health care claim or line item

        • LINLoop1Item Identification LOOPO可选(Optional)Repeat > 1
          LINCTPREF
          • 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

          • REF
            Reference Information
            O可选(Optional)
            Repeat 1

            To specify identifying information

        • NM1Loop5Individual or Organizational Name LOOPO可选(Optional)Repeat 10
          NM1PRVN2N3N4REFPER
          • 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

          • N3
            Party Location
            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 Information
            O可选(Optional)
            Repeat 20

            To specify identifying information

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

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

        • SVDLoop1Service Line Adjudication LOOPO可选(Optional)Repeat > 1
          SVDCASDTPAMT
          • SVD
            Service Line Adjudication
            M必须(Mandatory)
            Repeat 1

            To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers

          • CAS
            Claims Adjustment
            O可选(Optional)
            Repeat 99

            To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid

          • DTP
            Date or Time or Period
            O可选(Optional)
            Repeat 9

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

          • AMT
            Monetary Amount Information
            O可选(Optional)
            Repeat 20

            To indicate the total monetary amount

        • LQLoop1Industry Code Identification LOOPO可选(Optional)Repeat > 1
          LQFRM
          • LQ
            Industry Code Identification
            M必须(Mandatory)
            Repeat 1

            To identify standard industry codes

          • FRM
            Supporting Documentation
            M必须(Mandatory)
            Repeat 99

            To specify information in response to a codified questionnaire document

  • 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 00504
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

    Reference assigned to identify Implementation Convention