EDI 837 Institutional Claim (EDI 837I)

What is the EDI 837 Institutional 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 sent the proper 837 transaction set to payers. (See an example EDI 837 Q3 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.

EDI 837 Q3 Institutional Claim can be used to submit healthcare claim billing information, encounter information, or both. The EDI 837 Q3 can also be used to transmit healthcare 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 healthcare services within a specific healthcare/insurance industry segment.

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 about the rapid Integration of EDI Transactions in our X12 EDI case studies.

EDI 837 Workflow Example

EDI 837 Workflow Diagram

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 Q3 Format Example

Business Scenario 1 – 837 Institutional Claim

ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X223

The examples in this section have been created with a mixture of uppercase and lowercase letters. This demonstrates that this is an acceptable representation.

Transmission Explanation

PRIMARY PAYER SUBSCRIBER: John T Doe

SUBSCRIBER ADDRESS	125 City Avenue, Centerville, PA 17111
SEX	M
DOB	11/11/1926
MEDICARE INSURANCE ID#	030005074A
PAYER ID #	00435

PATIENT: Same as Primary Subscriber

DESTINATION PAYER: Medicare B

SUBMITTER: Jones Hospital

EDI#

12345

RECEIVER: Medicare

EDI#

00120

BILLING PROVIDER: Jones Hospital

NPI	9876540809
TIN	567891234
MEDICARE PROVIDER	#330127
ADDRESS	225 Main Street Barkley Building, Centerville, PA 17111

ATTENDING PHYSICIAN: John J Jones

UPIN #

B99937

PATIENT ACCOUNT NUMBER: 756048Q

DATE OF ADMISSION	09/11/96
STATEMENT PERIOD DATE	09/11/96 – 09/11/96
PLACE OF SERVICE	Inpatient Hospital
Occurrence Codes and Dates	A1 11/11/26 A2 11/01/91 B1 11/11/26 B2 01/01/87
Condition Codes	09
Value Codes	A2 $15.31
PRINCIPAL DIAGNOSIS CODE	366.9
SECONDARY DIAGNOSIS CODES	401.9 794.31
NUMBER OF COVERED DAYS	1
SERVICES
INSTITUTIONAL SERVICES RENDERED
REVENUE CODE	0305 HCPCS Procedure Code: 85025 Unit: 1 Price $13.39
REVENUE CODE	0730 HCPCS Procedure Code: 93005 Unit: 1 Price: $76.54
TOTAL CHARGES	$89.93

SECONDARY PAYER SUBSCRIBER: Jane S Doe (wife)

SUBSCRIBER ADDRESS	125 City Avenue, Centerville, PA 17111
SEX	F
DOB	12/11/1927
STATE TEACHERS ID#	222004433
PAYER ID #	1135

HEADER

ST837987654*005010X223~	ST TRANSACTION SET HEADER
BHT0019000123199609180932CH~	BHT BEGINNING OF HIERARCHICAL TRANSACTION

1000A SUBMITTER NAME

NM1412JONES HOSPITAL***4612345~	NM1 SUBMITTER NAME
PERICJANE DOETE9005555555~	PER SUBMITTER EDI CONTACT INFORMATION

1000B RECEIVER NAME

NM1*40*2*MEDICARE*****46*00120~

NM1 RECEIVER NAME

2000A BILLING PROVIDER

HL1201~	HL BILLING PROVIDER HIERARCHICAL LEVEL
PRVBIPXC*203BA0200N~	PRV BILLING PROVIDER SPECIALTY

2010AA BILLING PROVIDER NAME

NM1852JONES HOSPITAL***XX9876540809~	NM1 BILLING PROVIDER NAME INCLUDING NATIONAL PROVIDER ID
N3*225 MAIN STREET BARKLEY BUILDING~	N3 BILLING PROVIDER ADDRESS
N4CENTERVILLEPA*17111~	N4 BILLING PROVIDER LOCATION
REFEI567891234~	REF BILLING PROVIDER TAX IDENTIFICATION NUMBER
PERICCONNIETE3055551234~	PER BILLING PROVIDER CONTACT INFORMATION

2000B SUBSCRIBER HL LOOP

HL21220~	HL SUBSCRIBER HIERARCHICAL LEVEL
SBRP18*******MB~	SBR SUBSCRIBER INFORMATION

2010BA SUBSCRIBER NAME LOOP

NM1IL1DOEJOHNT*MI030005074A~	NM1 SUBSCRIBER NAME
N3*125 CITY AVENUE~	N3 SUBSCRIBER ADDRESS
N4CENTERVILLEPA*17111~	N4 SUBSCRIBER LOCATION
DMGD819261111*M~	DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

2010BB PAYER NAME LOOP

NM1PR2MEDICARE B***PI00435~	NM1 PAYER NAME
REFG2330127~	REF BILLING PROVIDER SECONDARY IDENTIFICATION

2300 CLAIM INFORMATION

CLM756048Q89.93*14:A:1AYY~	CLM CLAIM LEVEL INFORMATION
DTP434RD8*19960911~	DTP STATEMENT DATES
CL13*01~	CL1 INSTITUTIONAL CLAIM CODE
HI*BK:3669~	HI PRINCIPAL DIAGNOSIS CODES
HIBF:4019BF:79431~	HI OTHER DIAGNOSIS INFORMATION
HIBH:A1:D8:19261111BH:A2:D8:19911101* BH:B1:D8:19261111*BH:B2:D8:19870101~	HI OCCURRENCE INFORMATION
HI*BE:A2:::15.31~	HI VALUE INFORMATION
HI*BG:09~	HI CONDITION INFORMATION

2310A ATTENDING PROVIDER NAME

NM1711JONESJOHN*J~	NM1 ATTENDING PROVIDER
REF1GB99937~	REF ATTENDING PROVIDER SECONDARY IDENTIFICATION

2320 OTHER SUBSCRIBER INFORMATION

SBRS01351630STATE TEACHERS*****CI~	SBR OTHER SUBSCRIBER INFORMATION
OI*Y*Y~	OI OTHER INSURANCE COVERAGE INFORMATION

2330A OTHER SUBSCRIBER NAME

NM1IL1DOEJANES*MI222004433~	NM1 OTHER SUBSCRIBER NAME
N3*125 CITY AVENUE~	N3 OTHER SUBSCRIBER ADDRESS
N4CENTERVILLEPA*17111~	N4 OTHER SUBSCRIBER CITY, STATE, ZIP CODE

2330B OTHER PAYER NAME

NM1*PR*2*STATE TEACHERS*****PI*1135~

NM1 OTHER PAYER NAME

2400 SERVICE LINE

LX*1~	LX SERVICE LINE COUNTER
SV20305HC:8502513.39UN*1~	SV2 INSTITUTIONAL SERVICE
DTP472D8*19960911~	DTP DATE – SERVICE DATES

2400 SERVICE LINE

LX*2~	LX SERVICE LINE COUNTER
SV20730HC:9300576.54UN*3~	SV2 INSTITUTIONAL SERVICE
DTP472D8*19960911~	DTP DATE – SERVICE DATES

TRAILER

SE*42*987654~

SE TRANSACTION SET TRAILER

Source

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

EDI 837 Frequently Asked Questions

What tool parses EDI 837 and EDI 835 data to an SQL database? expand_more

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.

Can the eiConsole for X12 by PilotFish map EDI 837, EDI 278 and other transactions to FHIR resources? expand_more

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.

Does PilotFish offer a comprehensive rules engine for HIPAA-compliant EDI file validation and error reporting? expand_more

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.

Does PilotFish support current national claims routing functionalities? For example, a lookup query for optimized routing. expand_more

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.

Does PilotFish support data splitting such as ISA or claim level splitting for SNIP level validation? For example, good vs bad claim level or an enrollment level split. expand_more

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 FAQ pages for more

If you are curious about the software features, free trial, or a demo, we are ready to answer your questions.

X12, chartered by the American National Standards Institute for more than 35 years, develops and maintains EDI standards and XML schemas.