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.
To indicate the start of a transaction set and to assign a control number
To indicate the beginning of a transaction set.
To specify identifying numbers.
To supply the full name of an individual or organizational entity
To specify additional names or those longer than 35 characters in length
To specify the location of the named party
To specify the geographic place of the named party
To specify identifying numbers.
To identify a person or office to whom administrative communications should be directed
To specify the identifying characteristics of a provider
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
To supply the full name of an individual or organizational entity
To specify additional names or those longer than 35 characters in length
To specify the location of the named party
To specify the geographic place of the named party
To specify identifying numbers.
To identify a person or office to whom administrative communications should be directed
To record claim information specific to the primary insured and the insurance carrier for that insured
To specify any or all of a date, a time, or a time period
To supply the full name of an individual or organizational entity
To specify additional names or those longer than 35 characters in length
To specify the location of the named party
To specify the geographic place of the named party
To supply demographic information
To identify a person or office to whom administrative communications should be directed
To specify identifying numbers.
To supply patient information
To supply the full name of an individual or organizational entity
To specify additional names or those longer than 35 characters in length
To specify the location of the named party
To specify the geographic place of the named party
To supply demographic information
To identify a person or office to whom administrative communications should be directed
To specify identifying numbers.
To specify basic data about the claim
To specify any or all of a date, a time, or a time period
To supply information specific to hospital claims
To supply orthodontic information
To specify the status of individual teeth
To identify the type and transmission of paperwork or supporting information
To specify basic data about the contract
To supply disability information
To specify the results of the utilization review
To indicate the total monetary amount.
To specify identifying numbers.
To transmit a fixed format record
To transmit information in a free-form format, if necessary, for comment or special instruction
To supply information related to the ambulance service rendered to a patient
To supply information related to the chiropractic service rendered to a patient
To supply information regarding a physician's certification for durable medical equipment
To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy
To supply information regarding certification of medical necessity for home oxygen therapy
To supply information related to Pacemaker registry.
To supply information on conditions
To specify medical procedures codes and the dates associated with them
To specify a code and the amount, quantity associated with it, or both
To provide characteristics that may have multiple values
To specify quantity information.
To specify pricing or repricing information about a health care claim or line item
To indicate that the next segment begins a loop
To supply the full name of an individual or organizational entity
To specify the identifying characteristics of a provider
To specify additional names or those longer than 35 characters in length
To specify the location of the named party
To specify the geographic place of the named party
To identify a person or office to whom administrative communications should be directed
To indicate that the loop immediately preceding this segment is complete
To reference a line number in a transaction set.
To specify the claim service detail for a Health Care professional
To specify the claim service detail for a Health Care institution
To specify the claim service detail for dental work
To specify the claim service detail for prescription drugs
To specify basic item identification data.
To specify pricing information
To specify the claim service detail for durable medical equipment
To specify the claim service detail for anesthesia
To specify the claim service detail for drug services that have been adjudicated
To provide characteristics that may have multiple values
To identify the type and transmission of paperwork or supporting information
To supply information related to the ambulance service rendered to a patient
To supply information related to the chiropractic service rendered to a patient
To supply information regarding a physician's certification for durable medical equipment
To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy
To supply information regarding certification of medical necessity for home oxygen therapy
To supply information on conditions
To specify any or all of a date, a time, or a time period
To specify quantity information.
To specify basic data about the contract
To specify identifying numbers.
To indicate the total monetary amount.
To transmit a fixed format record
To transmit information in a free-form format, if necessary, for comment or special instruction
To specify the information about services that are purchased
To specify pricing or repricing information about a health care claim or line item
To indicate that the next segment begins a loop
To supply the full name of an individual or organizational entity
To specify the identifying characteristics of a provider
To specify additional names or those longer than 35 characters in length
To specify the location of the named party
To specify the geographic place of the named party
To identify a person or office to whom administrative communications should be directed
To indicate that the loop immediately preceding this segment is complete
To indicate that the next segment begins a loop
To record claim information specific to the primary insured and the insurance carrier for that insured
To specify the adjudication codes for a claim service item
To indicate the total monetary amount.
To supply demographic information
To specify information associated with other health insurance coverage
To supply the full name of an individual or organizational entity
To specify additional names or those longer than 35 characters in length
To specify the location of the named party
To specify the geographic place of the named party
To identify a person or office to whom administrative communications should be directed
To specify any or all of a date, a time, or a time period
To specify identifying numbers.
To indicate that the loop immediately preceding this segment is complete
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments).
