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EDI 837 Q1 Format Example

EDI 837 Q1 Healthcare Claim: Professional


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: 837 Q1 for professionals, 837 Q2 for dental practices, and 837 Q3 for institutions. Providers sent the proper 837 transaction set to payers. (See an example 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 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, cost(s) of said treatment.

The 837 Q1 Healthcare Claim: Professional is used by providers and health plans exchanging 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.

EDI 837 Q1 Healthcare Claim Loaded Into Healthcare Data Mapping Software

 

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.

HL7 is the registered trademark of Health Level Seven International. X12, chartered by the American National Standards Institute for more than 35 years, develops and maintains EDI standards and XML schemas.

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