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.
To indicate the start of a transaction set and to assign a control number
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
To specify identifying information
To supply the full name of an individual or organizational entity
To specify additional names
To specify the location of the named party
To specify the geographic place of the named party
To specify identifying information
To identify a person or office to whom administrative communications should be directed
To identify dependencies among and the content of hierarchically related groups of data segments
To specify the identifying characteristics of a provider
To record information specific to the primary insured and the insurance carrier for that insured
To supply patient information
To specify any or all of a date, a time, or a time period
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
To specify the location of the named party
To specify the geographic place of the named party
To supply demographic information
To specify identifying information
To identify a person or office to whom administrative communications should be directed
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 or transmission or both of paperwork or supporting information
To specify basic data about the contract or contract line item
To supply disability information
To specify the results of the utilization review
To indicate the total monetary amount
To specify identifying information
To transmit a fixed-format record or matrix contents
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 the certification of a home health care patient
To supply information related to Pacemaker registry
To supply information on conditions
To supply information related to the delivery of health care
To specify quantity information
To specify pricing or repricing information about a health care claim or line item
To supply information related to the home health care plan of treatment and services
To specify the delivery pattern of health care services
To supply the full name of an individual or organizational entity
To specify the identifying characteristics of a provider
To specify additional names
To specify the location of the named party
To specify the geographic place of the named party
To specify identifying information
To identify a person or office to whom administrative communications should be directed
To record information specific to the primary insured and the insurance carrier for that insured
To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid
To indicate the total monetary amount
To supply demographic information
To specify information associated with other health insurance coverage
To provide claim-level data related to the adjudication of Medicare inpatient claims
To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting
To supply the full name of an individual or organizational entity
To specify additional names
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 information
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 identify a tooth by number and, if applicable, one or more tooth surfaces
To specify the claim service detail for prescription drugs
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 supply information related to the delivery of health care
To identify the type or transmission or both 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 physical measurements or counts, including dimensions, tolerances, variances, and weights
(See Figures Appendix for example of use of C001)
To specify basic data about the contract or contract line item
To specify identifying information
To indicate the total monetary amount
To transmit a fixed-format record or matrix contents
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 provide the receiving school district or postsecondary institution with a notice of the immunization status of the student
To specify the delivery pattern of health care services
To specify pricing or repricing information about a health care claim or line item
To specify basic item identification data
To specify pricing information
To specify identifying information
To supply the full name of an individual or organizational entity
To specify the identifying characteristics of a provider
To specify additional names
To specify the location of the named party
To specify the geographic place of the named party
To specify identifying information
To identify a person or office to whom administrative communications should be directed
To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers
To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid
To specify any or all of a date, a time, or a time period
Code to transmit standard industry codes
To specify information in response to a codified questionnaire document
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)
