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EDI 837 Format Example

EDI 837 Healthcare Claim: Dental

What is the EDI 837 Dental 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 send the proper 837 transaction set to payers. (See an example 837 Q2 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 Healthcare Claim Payment transaction set.

The claim information for a single care encounter between patient and provider basically includes: patient descriptors; the condition for which treatment was provided; services provided; cost(s) of said treatment.

The 837 Q2 Healthcare Claim: Dental transaction set can be used to submit healthcare claim billing information, encounter information, or both, from providers of healthcare services to payers, either directly or via intermediary billers and claims clearinghouses.

Read our X12 EDI case studies on the rapid Integration of EDI Transactions.

EDI 837 Q2 Example of Dental Healthcare Claim in EDI Processing Software

EDI 837 Dental Claim in Data Mapper
(Click to enlarge)

 

EDI 837 Workflow Example

EDI Healthcare Transaction Workflow Diagram with PilotFish Integration Engine

(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 Q2 Format Example

Commercial Health Insurance

ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X224

The patient is a different person than the subscriber. The payer is a commercial health insurance company.

Transmission Explanation

HEADER

ST*837*3456*005010X224~ST TRANSACTION SET HEADER
BHT*0019*00*0123*20061123*1023*CH~BHT TRANSACTION SET HIERARCHY AND CONTROL INFORMATION

1000A SUBMITTER

NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~NM1 SUBMITTER
PER*IC*JERRY*TE*7176149999~PER SUBMITTER EDI CONTACT INFORMATION

1000B RECEIVER

NM1*40*2*INSURANCE COMPANY XYZ*****46*66783JJT~NM1 RECEIVER

 

2000A BILLING PROVIDER HL LOOP

HL*1**20*1~HIERARCHAL LEVEL 1

 

2010AA BILLING PROVIDER

NM1*85*2*DENTAL ASSOCIATES*****XX*1234567890~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’S TAX IDENTIFICATION

 

2000B SUBSCRIBER HL LOOP

HL*2*1*22*1~HIERARCHAL LEVEL 2
SBR*P********CI~SBR SUBSCRIBER INFORMATION

 

2010BA SUBSCRIBER

NM1*IL*1*SMITH*JANE****MI*111223333~NM1 SUBSCRIBER’S NAME

 

2010BB SUBSCRIBER/PAYER

NM1*PR*2*INSURANCE COMPANY XYZ*****PI*66783JJT~NM1 PAYER’S NAME

 

2000C PATIENT’S HL LOOP

HL*3*2*23*0~HIERARCHAL LEVEL 3
PAT*19~PAT PATIENT INFORMATION

 

2010CA PATIENT

NM1*QC*1*SMITH*TED~NM1 PATIENT’S NAME
N3*236 N MAIN ST~N3 PATIENT’S ADDRESS
N4*MIAMI*FL*33413~N4 PATIENT’S CITY
DMG*D8*19920501*M~DMG PATIENT DEMOGRAPHIC INFORMATION

 

2300 CLAIM

CLM*26403774*150***11:B:1*Y*A*Y*I~CLM HEALTH CLAIM INFORMATION
DTP*472*D8*20061029~DTP DATE – SERVICE DATE
REF*D9*17312345600006351~REF VAN CLAIM NUMBER

 

2310B RENDERING PROVIDER

NM1*82*1*KILDARE*BEN****XX*9876543210~NM1 RENDERING PROVIDER’S NAME
PRV*PE*PXC*1223G0001X~PRV RENDERING PROVIDER INFORMATION

 

2400 SERVICE LINE

LX*1~LX SERVICE LINE NUMBER
SV3*AD:D2150*100****1~SV3 DENTAL SERVICE
TOO*JP*12*M:O~TOO TOOTH NUMBER/SURFACES

 

2400 SERVICE LINE

LX*2~LX SERVICE LINE NUMBER
SV3*AD:D1110*50****1~SV3 DENTAL SERVICE

 

TRAILER

SE*31*3456~SE TRANSACTION SET TRAILER

 

Source

Accredited Standards Committee X12. ASC X12 Standard [Table Data]. Data Interchange Standards Association, Inc., Falls Church, VA. ASC X12 Examples

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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