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EDI 837-Q3 Format Example

EDI 837-Q3 Institutional Claim


EDI 837-Q3 can be used to submit health care claim billing information, encounter information, or both. Submitters can be providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses.

EDI 837-Q3 can also be used to transmit health care 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 health care services within a specific health care/insurance industry segment.

EDI 837-Q3 Transaction Format Example

 

Providers of healthcare products or services may include entities such as physicians, hospitals and other medical facilities or suppliers, dentists, and pharmacies, and entities providing medical information to meet regulatory requirements. The payer refers to a third party entity that pays claims or administers the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), 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. A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific health care/insurance industry segment.

 

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

 

Transmission Explanation

HEADER

ST*837*987654*005010X223~ ST TRANSACTION SET HEADER
BHT*0019*00*0123*19960918*0932*CH~ BHT BEGINNING OF HIERARCHICAL TRANSACTION

 

1000A SUBMITTER NAME

NM1*41*2*JONES HOSPITAL*****46*12345~ NM1 SUBMITTER NAME
PER*IC*JANE DOE*TE*9005555555~ PER SUBMITTER EDI CONTACT INFORMATION

 

1000B RECEIVER NAME

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

 

2000A BILLING PROVIDER

HL*1**20*1~ HL BILLING PROVIDER HIERARCHICAL LEVEL
PRV*BI*PXC*203BA0200N~ PRV BILLING PROVIDER SPECIALTY

 

2010AA BILLING PROVIDER NAME

NM1*85*2*JONES HOSPITAL*****XX*9876540809~ NM1 BILLING PROVIDER NAME INCLUDING NATIONAL PROVIDER ID
N3*225 MAIN STREET BARKLEY BUILDING~ N3 BILLING PROVIDER ADDRESS
N4*CENTERVILLE*PA*17111~ N4 BILLING PROVIDER LOCATION
REF*EI*567891234~ REF BILLING PROVIDER TAX IDENTIFICATION NUMBER
PER*IC*CONNIE*TE*3055551234~ PER BILLING PROVIDER CONTACT INFORMATION

 

2000B SUBSCRIBER HL LOOP

HL*2*1*22*0~ HL SUBSCRIBER HIERARCHICAL LEVEL
SBR*P*18*******MB~ SBR SUBSCRIBER INFORMATION

 

2010BA SUBSCRIBER NAME LOOP

NM1*IL*1*DOE*JOHN*T***MI*030005074A~ NM1 SUBSCRIBER NAME
N3*125 CITY AVENUE~ N3 SUBSCRIBER ADDRESS
N4*CENTERVILLE*PA*17111~ N4 SUBSCRIBER LOCATION
DMG*D8*19261111*M~ DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

 

2010BB PAYER NAME LOOP

NM1*PR*2*MEDICARE B*****PI*00435~ NM1 PAYER NAME
REF*G2*330127~ REF BILLING PROVIDER SECONDARY IDENTIFICATION

 

2300 CLAIM INFORMATION

CLM*756048Q*89.93**14:A:1*A*Y*Y~ CLM CLAIM LEVEL INFORMATION
DTP*434*RD8*19960911~ DTP STATEMENT DATES
CL1*3**01~ CL1 INSTITUTIONAL CLAIM CODE
HI*BK:3669~ HI PRINCIPAL DIAGNOSIS CODES
HI*BF:4019*BF:79431~ HI OTHER DIAGNOSIS INFORMATION
HI*BH:A1:D8:19261111*BH: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

NM1*71*1*JONES*JOHN*J~ NM1 ATTENDING PROVIDER
REF*1G*B99937~ REF ATTENDING PROVIDER SECONDARY IDENTIFICATION

 

2320 OTHER SUBSCRIBER INFORMATION

SBR*S*01*351630*STATE TEACHERS*****CI~ SBR OTHER SUBSCRIBER INFORMATION
OI***Y***Y~ OI OTHER INSURANCE COVERAGE INFORMATION

 

2330A OTHER SUBSCRIBER NAME

NM1*IL*1*DOE*JANE*S***MI*222004433~ NM1 OTHER SUBSCRIBER NAME
N3*125 CITY AVENUE~ N3 OTHER SUBSCRIBER ADDRESS
N4*CENTERVILLE*PA*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
SV2*0305*HC:85025*13.39*UN*1~ SV2 INSTITUTIONAL SERVICE
DTP*472*D8*19960911~ DTP DATE – SERVICE DATES

 

2400 SERVICE LINE

LX*2~ LX SERVICE LINE COUNTER
SV2*0730*HC:93005*76.54*UN*3~ SV2 INSTITUTIONAL SERVICE
DTP*472*D8*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.

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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