EDI 837 Professional Healthcare Claim (EDI 837P)
What is the EDI 837 Professional Claim Transaction Set?
The EDI 837 Healthcare Claim transaction set and format have been specified by HIPAA 5010 standards for the electronic exchange of healthcare claim information. HIPAA 5010 837 transaction sets used are: EDI 837 Q1 for professionals, EDI 837 Q2 for dental practices, and EDI 837 Q3 for institutions. Providers send the proper EDI 837 transaction set to payers. (See an example EDI 837 Q1 below.) This transaction set can be used to submit healthcare claim billing information, encounter information, or both.
The payer refers to a third-party entity that pays claims or administers the insurance product or benefit or both. The payer may be an insurance company, Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), government agency (Medicare, Medicaid, 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.
Providers may send EDI 837s directly to payers or via clearinghouses. The EDI 837 transaction set can also be used to transmit healthcare claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required. It may also be used between payers and regulatory agencies.
Health insurers and other payers send their payments and coordination of benefits information back to providers via the EDI 835 transaction set.
The claim information for a single care encounter between patient and provider basically includes: patient descriptors, condition for which treatment was provided, services provided, and cost(s) of said treatment.
The EDI 837 Q1 Healthcare Claim: Professional is used by providers and health plans to exchange professional (medical) healthcare claims electronically. This transaction set is sent by the providers to payers either directly or indirectly via clearinghouses. Per this standard, providers of healthcare products or services may include entities such as physicians, hospitals and other medical facilities or suppliers, dentists, and pharmacies (not retailers), and entities providing medical information to meet regulatory requirements.
A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or specific healthcare or insurance industry segment.
Read our case study on the rapid Integration of EDI 834 & EDI 837 Transactions.
EDI 837 Professional Claim in Data Mapper
(Click to enlarge)
EDI 837 Workflow Example
(EDI 837 Workflow Diagram – Click to enlarge.)
Providers or third-party services send the EDI 837 Healthcare Claim to payers. The optional EDI 275 Additional Patient Information (Unsolicited) may also be sent with attachments. The payer or clearinghouse system returns an EDI 999 Implementation Acknowledgment to confirm receipt of the incoming EDI 837 Healthcare Claim. The payer may send an EDI 277 Claim Acknowledgement of all claims received in the payer’s pre-processing system.
An EDI 276 Claim Status Request is sent to verify the status of the claim. The EDI 277 Claim Status Response is sent by the payer. The payer may also send an EDI 277 Request for Additional Information. The EDI 275 Additional Information (Solicited) is sent in response and may include patient record attachments.
With aspects of the claim verified, the payer sends the EDI 277 Claim Pending Status Information. The EDI 835 Claim Payment/Advice is used to make payments to healthcare providers and/or provide Explanations of Benefits (EOBs). The EDI 835 is used to detail and track the payment to the claim.
EDI 837 Frequently Asked Questions
Pilotfish’s eiConsole Interface Engine can configure interfaces to parse EDI 835, EDI 837 or any other X12 EDI message and transform them into SQL inserts. Read more about X12 EDI Parsing.
Yes, the PilotFish Mapper in the eiConsole for X12 can map any X12 EDI transaction to any target transaction, resources such as FHIR and API’s. The Data Mapper can also connect and map directly to SQL database tables.
Absolutely. PilotFish expertly conducts SNIP validations, ensuring both integrity and compliance. For example, EDI 835 files that are generated from EDI 837 files. This meticulous validation process not only identifies errors but also presents the findings in a user-friendly XML format. Additionally, users have the flexibility to either generate detailed reports or opt for exceptions based on these validation outcomes.
Yes, PilotFish can do a lookup query with its software, which is optimized for routing an EDI 837 claims transaction set. The query determines the correct destination for each claim based on the patient’s insurance information. PilotFish can send an EDI 835 with information about the payment, adjustment, denial and other claim details.
Yes, PilotFish has customers that require splitting based on some level of validation. For instance, in an 837 file with multiple claims, PilotFish can separate the data into two files, allowing the valid file to continue processing if the other encounters issues.
Check out our EDI FAQ pages for more.
EDI 837 Q1 Format Example
Commercial Health Insurance
ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X222
A patient is a different person than the Subscriber. The payer is a commercial health insurance company.
Transmission Explanation
HEADER
| ST*837*0021*005010X222~ | ST TRANSACTION SET HEADER |
| BHT*0019*00*244579*20061015*1023*CH~ | BHT BEGINNING OF HIERARCHICAL TRANSACTION |
1000A SUBMITTER
| NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~ | NM1 SUBMITTER NAME |
| PER*IC*JERRY*TE*3055552222*EX*231~ | PER SUBMITTER EDI CONTACT INFORMATION |
1000B RECEIVER
| NM1*40*2*KEY INSURANCE COMPANY*****46*66783JJT~ | NM1 RECEIVER NAME |
2000A BILLING PROVIDER HL LOOP
| HL*1**20*1~ | HL – BILLING PROVIDER |
| PRV*BI*PXC*203BF0100Y~ | PRV BILLING PROVIDER SPECIALTY INFORMATION |
2010AA BILLING PROVIDER
| NM1*85*2*BEN KILDARE SERVICE*****XX*9876543210~ | NM1 BILLING PROVIDER NAME |
| N3*234 SEAWAY ST~ | N3 BILLING PROVIDER ADDRESS |
| N4*MIAMI*FL*33111~ | N4 BILLING PROVIDER LOCATION |
| REF*EI*587654321~ | REF – BILLING PROVIDER TAX IDENTIFICATION |
2010AB PAY-TO PROVIDER
| NM1*87*2~ | NM1 PAY-TO PROVIDER NAME |
| N3*2345 OCEAN BLVD~ | N3 PAY-TO PROVIDER ADDRESS |
| N4*MIAMI*FL*33111~ | N4 PAY-TO PROVIDER CITY |
2000B SUBSCRIBER HL LOOP
| HL*2*1*22*1~ | HL – SUBSCRIBER |
| SBR*P**2222-SJ******CI~ | SBR SUBSCRIBER INFORMATION |
2010BA SUBSCRIBER
| NM1*IL*1*SMITH*JANE****MI*JS00111223333~ | NM1 SUBSCRIBER NAME |
| DMG*D8*19430501*F~ | DMG SUBSCRIBER DEMOGRAPHIC INFORMATION |
2010BB PAYER
| NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~ | NM1 PAYER NAME |
| REF*G2*KA6663~ | REF BILLING PROVIDER SECONDARY IDENTIFICATION |
2000C PATIENT HL LOOP
| HL*3*2*23*0~ | HL – PATIENT |
| PAT*19~ | PAT PATIENT INFORMATION |
2010CA PATIENT
| NM1*QC*1*SMITH*TED~ | NM1 PATIENT NAME |
| N3*236 N MAIN ST~ | N3 PATIENT ADDRESS |
| N4*MIAMI*FL*33413~ | N4 PATIENT CITY/STATE/ZIP |
| DMG*D8*19730501*M~ | DMG PATIENT DEMOGRAPHIC INFORMATION |
2300 CLAIM
| CLM*26463774*100***11:B:1*Y*A*Y*I~ | CLM CLAIM LEVEL INFORMATION |
| REF*D9*17312345600006351~ | REF CLAIM IDENTIFICATION NUMBER FOR CLEARING HOUSES (Added by C.H.) |
| HI*BK:0340*BF:V7389~ | HI HEALTHCARE DIAGNOSIS CODES |
2400 SERVICE LINE
| LX*1~ | LX SERVICE LINE COUNTER |
| SV1*HC:99213*40*UN*1***1~ | SV1 PROFESSIONAL SERVICE |
| DTP*472*D8*20061003~ | DTP DATE – SERVICE DATE(S) |
2400 SERVICE LINE
| LX*2~ | LX SERVICE LINE COUNTER |
| SV1*HC:87070*15*UN*1***1~ | SV1 PROFESSIONAL SERVICE |
| DTP*472*D8*20061003~ | DTP DATE – SERVICE DATE(S) |
2400 SERVICE LINE
| LX*3~ | LX SERVICE LINE COUNTER |
| SV1*HC:99214*35*UN*1***2~ | SV1 PROFESSIONAL SERVICE |
| DTP*472*D8*20061010~ | DTP DATE – SERVICE DATE(S) |
2400 SERVICE LINE
| LX*4~ | LX SERVICE LINE COUNTER |
| SV1*HC:86663*10*UN*1***2~ | SV1 PROFESSIONAL SERVICE |
| DTP*472*D8*20061010~ | DTP DATE – SERVICE DATE(S) |
TRAILER
| SE*42*0021~ | SE TRANSACTION SET TRAILER |
Source
Accredited Standards Committee X12. ASC X12 Standard [Table Data]. Data Interchange Standards Association, Inc., McLean, VA.
X12, chartered by the American National Standards Institute for more than 35 years, develops and maintains EDI standards and XML schemas.