EDI 837 claim file format
EDI 837 File Format Types
The healthcare EDI 837 transaction set provides the HIPAA 5010 standard requirements EDI capable organization to submit claims. The file contains information about a patient claim and is submitted to healthcare plans for payment. As of March 31, 2012, healthcare providers should be compliant with version 5010 of the HIPAA EDI standards. One of the major changes from 4010 to 5010 is expanding the ICD codes. The ICD9 codes in 4010 were expanded to the 5010 ICD10 diagnostic codes. We recomend utilizing our free EDI Viewer to easly navigate claim files and detect validation errors.
EDI 837 Sample File:
There are three types of 837s:
- 837I – Intuitional billing provides claim information by hospitals and nursing facilities. The standardized paper form used is the UB-04.
- 837P – Professional billing is generated by physicians and other non-instructional providers that perform outpatient and inpatient healthcare services. Typically, if this came in as a paper form, it would be provided in the CMS-1500 form.
- 837D – Dental claims are used by dental providers.
Loops and Segments of an EDI 837 Claim File
The EDI 837 is broken into blocks of Loops. Every Loop has different types of Segments that also contain Elements and Sub Data Elements. An EDI 837 typically contains patient information, patient’s condition, the service provided to the patient, and cost for the treatment.
The major loops required to submit claims are provided as below:
- 2000A – Billing Provider
- 2000B – Subscriber information
- 2000C – Client information if subscriber is included
- 2300 – Claim information
- 2400 – Service Line information
Reading an 837 File
Let’s take a look at some of those loops using one of our EDI Tools – X12 Studio Toolbox. X12 Studio shows the EDI in an easy to read hierarchical format:
Segments include data elements and sub-elements. X12.org maintains the 5010 X12 HIPAA transaction sets.
Element Identifier Codes of an EDI 837 file:
- 41 - Claim Creator
- 40 - Claim Receiver
- 85 - Billing Provider
- 82 - Rendering Provider
- DN - Referring Provider
- IC - Information Contact
- 77 - Service Location
- 472 - Date of Service
- SY - Social Security Number
- EI - Tax ID (EIN)
- XX - NPI
- Y4 - Claim Casualty Number
- HC - Standard CPT Code
- ABK - Principal Diagnosis
- ABF - Diagnosis
Caliber Health’s T-Connect EDI Solutions are built for organization to better process healthcare transactions.