EDI 837 Professional Healthcare Claim (EDI 837P)

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 a specific healthcare or insurance industry segment.

Discover how others have tackled EDI 837 integration challenges. Read our case studies: Faster Claims Processing and Scaleable Medicaid Data Integration.