To supply the full name of an individual or organizational entity
To specify additional names
To specify the location of the named party
To specify the geographic place of the named party
To specify identifying information
To identify a person or office to whom administrative communications should be directed
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- X12 EDI Release 00602
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- 837
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837Health Care Claim
This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Transaction Set (837) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It 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. For purposes of this standard, providers of health care 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.
To indicate the start of a transaction set and to assign a control number
To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time
To specify identifying information
To identify dependencies among and the content of hierarchically related groups of data segments
To specify the identifying characteristics of a provider
To record information specific to the primary insured and the insurance carrier for that insured
To supply patient information
To specify any or all of a date, a time, or a time period
To specify the currency (dollars, pounds, francs, etc.) used in a transaction
To supply the full name of an individual or organizational entity
To specify additional names
To specify the location of the named party
To specify the geographic place of the named party
To supply demographic information
To specify identifying information
To identify a person or office to whom administrative communications should be directed
To specify language, type of usage, and proficiency or fluency
To specify basic data about the claim
To specify any or all of a date, a time, or a time period
To supply information specific to hospital claims
To supply orthodontic information
To specify the status of individual teeth
To identify the type or transmission or both of paperwork or supporting information
To specify basic data about the contract or contract line item
To supply disability information
To specify the results of the utilization review
To indicate the total monetary amount
To specify identifying information
To transmit a fixed-format record or matrix contents
To transmit information in a free-form format, if necessary, for comment or special instruction
To supply information related to the ambulance service rendered to a patient
To supply information related to the chiropractic service rendered to a patient
To supply information regarding a physician's certification for durable medical equipment
To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy
To supply information regarding certification of medical necessity for home oxygen therapy
To supply information related to the certification of a home health care patient
To supply information related to Pacemaker registry
To supply information on conditions
To supply information related to the delivery of health care
To specify quantity information
To specify pricing or repricing information about a health care claim or line item
To supply information related to the home health care plan of treatment and services
To specify the delivery pattern of health care services
To supply the full name of an individual or organizational entity
To specify the identifying characteristics of a provider
To specify additional names
To specify the location of the named party
To specify the geographic place of the named party
To specify identifying information
To identify a person or office to whom administrative communications should be directed
To record information specific to the primary insured and the insurance carrier for that insured
To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid
To supply Claim Adjustment Reason Codes and amounts as needed for an entire claim or for a particular service within the claim being paid
To indicate the total monetary amount
To supply demographic information
To specify information associated with other health insurance coverage
To provide claim level data related to the adjudication of inpatient claims
To provide claim level data related to the adjudication of outpatient claims
To supply the full name of an individual or organizational entity
To specify additional names
To specify the location of the named party
To specify the geographic place of the named party
To identify a person or office to whom administrative communications should be directed
To specify any or all of a date, a time, or a time period
To specify identifying information
To reference a line number in a transaction set
To specify the service line item detail for a health care professional
To specify the service line item detail for a health care institution
To specify the service line item detail for dental work
To identify a tooth by number and, if applicable, one or more tooth surfaces
To specify the claim service detail for prescription drugs
To specify the claim service detail for durable medical equipment
To specify the claim service detail for anesthesia
To specify the claim service detail for drug services that have been adjudicated
To supply information related to the delivery of health care
To identify the type or transmission or both of paperwork or supporting information
To supply information related to the ambulance service rendered to a patient
To supply information related to the chiropractic service rendered to a patient
To supply information regarding a physician's certification for durable medical equipment
To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy
To supply information regarding certification of medical necessity for home oxygen therapy
To supply information on conditions
To specify any or all of a date, a time, or a time period
To specify quantity information
To specify physical measurements or counts, including dimensions, tolerances, variances, and weights (See Figures Appendix for example of use of C001)
To specify basic data about the contract or contract line item
To specify identifying information
To indicate the total monetary amount
To transmit a fixed-format record or matrix contents
To transmit information in a free-form format, if necessary, for comment or special instruction
To specify the information about services that are purchased
To provide the receiving school district or postsecondary institution with a notice of the immunization status of the student
To specify the delivery pattern of health care services
To specify pricing or repricing information about a health care claim or line item
To specify basic item identification data
To specify pricing information
To specify identifying information
To specify the claim service detail for prescription drugs
To specify the claim service detail for drug services that have been adjudicated
To supply the full name of an individual or organizational entity
To specify the identifying characteristics of a provider
To specify additional names
To specify the location of the named party
To specify the geographic place of the named party
To specify identifying information
To identify a person or office to whom administrative communications should be directed
To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers
To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid
To supply Claim Adjustment Reason Codes and amounts as needed for an entire claim or for a particular service within the claim being paid
To specify any or all of a date, a time, or a time period
To indicate the total monetary amount
To report information
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)
Segment
X12 EDI Release 00602
To indicate the start of a transaction set and to assign a control number
Elements
Code uniquely identifying a Transaction Set
Codes (320)- 100Insurance Plan Description
- 101Name and Address Lists
- 102Associated Data
- 103Abandoned Property Filings
- 104Air Shipment Information
- 105Business Entity Filings
- 106Motor Carrier Rate Proposal
- 107Request for Motor Carrier Rate Proposal
- 108Response to a Motor Carrier Rate Proposal
- 109Vessel Content Details
- 110Air Freight Details and Invoice
- 111Individual Insurance Policy and Client Information
- 112Property Damage Report
- 113Election Campaign and Lobbyist Reporting
- 120Vehicle Shipping Order
- 121Vehicle Service
- 124Vehicle Damage
- 125Multilevel Railcar Load Details
- 126Vehicle Application Advice
- 127Vehicle Baying Order
- 128Dealer Information
- 129Vehicle Carrier Rate Update
- 130Student Educational Record (Transcript)
- 131Student Educational Record (Transcript) Acknowledgment
- 132Human Resource Information
- 133Educational Institution Record
- 135Student Aid Origination Record
- 138Educational Testing and Prospect Request and Report
- 139Student Loan Guarantee Result
- 140Product Registration
- 141Product Service Claim Response
- 142Product Service Claim
- 143Product Service Notification
- 144Student Loan Transfer and Status Verification
- 146Request for Student Educational Record (Transcript)
- 147Response to Request for Student Educational Record (Transcript)
- 148Report of Injury, Illness or Incident
- 149Notice of Tax Adjustment or Assessment
- 150Tax Rate Notification
- 151Electronic Filing of Tax Return Data Acknowledgment
- 152Statistical Government Information
- 153Unemployment Insurance Tax Claim or Charge Information
- 154Secured Interest Filing
- 155Business Credit Report
- 157Notice of Power of Attorney
- 158Tax Jurisdiction Sourcing
- 159Motion Picture Booking Confirmation
- 160Transportation Automatic Equipment Identification
- 161Train Sheet
- 163Transportation Appointment Schedule Information
- 170Revenue Receipts Statement
- 175Court and Law Enforcement Notice
- 176Court Submission
- 179Environmental Compliance Reporting
- 180Return Merchandise Authorization and Notification
- 185Royalty Regulatory Report
- 186Insurance Underwriting Requirements Reporting
- 187Premium Audit Request and Return
- 188Educational Course Inventory
- 189Application for Admission to Educational Institutions
- 190Student Enrollment Verification
- 191Student Loan Pre-Claims and Claims
- 194Grant or Assistance Application
- 195Federal Communications Commission (FCC) License Application
- 196Contractor Cost Data Reporting
- 197Real Estate Title Evidence
- 198Loan Verification Information
- 199Real Estate Settlement Information
- 200Mortgage Credit Report
- 201Residential Loan Application
- 202Secondary Mortgage Market Loan Delivery
- 203Secondary Mortgage Market Investor Report
- 204Motor Carrier Load Tender
- 205Mortgage Note
- 206Real Estate Inspection
- 210Motor Carrier Freight Details and Invoice
- 211Motor Carrier Bill of Lading
- 212Motor Carrier Delivery Trailer Manifest
- 213Motor Carrier Shipment Status Inquiry
- 214Transportation Carrier Shipment Status Message
- 215Motor Carrier Pickup Manifest
- 216Motor Carrier Shipment Pickup Notification
- 217Motor Carrier Loading and Route Guide
- 219Logistics Service Request
- 220Logistics Service Response
- 222Cartage Work Assignment
- 223Consolidators Freight Bill and Invoice
- 224Motor Carrier Summary Freight Bill Manifest
- 225Response to a Cartage Work Assignment
- 227Trailer Usage Report
- 228Equipment Inspection Report
- 240Motor Carrier Package Status
- 242Data Status Tracking
- 244Product Source Information
- 245Real Estate Tax Service Response
- 248Account Assignment/Inquiry and Service/Status
- 249Animal Toxicological Data
- 250Purchase Order Shipment Management Document
- 251Pricing Support
- 252Insurance Producer Administration
- 255Underwriting Information Services
- 256Periodic Compensation
- 259Residential Mortgage Insurance Explanation of Benefits
- 260Application for Mortgage Insurance Benefits
- 261Real Estate Information Request
- 262Real Estate Information Report
- 263Residential Mortgage Insurance Application Response
- 264Mortgage Loan Default Status
- 265Real Estate Title Insurance Services Order
- 266Mortgage or Property Record Change Notification
- 267Individual Life, Annuity and Disability Application
- 268Annuity Activity
- 269Health Care Benefit Coordination Verification
- 270Eligibility, Coverage or Benefit Inquiry
- 271Eligibility, Coverage or Benefit Information
- 272Property and Casualty Loss Notification
- 273Insurance/Annuity Application Status
- 274Healthcare Provider Information
- 275Patient Information
- 276Health Care Claim Status Request
- 277Health Care Information Status Notification
- 278Health Care Services Review Information
- 280Voter Registration Information
- 283Tax or Fee Exemption Certification
- 284Commercial Vehicle Safety Reports
- 285Commercial Vehicle Safety and Credentials Information Exchange
- 286Commercial Vehicle Credentials
- 288Wage Determination
- 290Cooperative Advertising Agreements
- 300Reservation (Booking Request) (Ocean)
- 301Confirmation (Ocean)
- 303Booking Cancellation (Ocean)
- 304Shipping Instructions
- 309Customs Manifest
- 310Freight Receipt and Invoice (Ocean)
- 311Canada Customs Information
- 312Arrival Notice (Ocean)
- 313Shipment Status Inquiry (Ocean)
- 315Status Details (Ocean)
- 317Delivery/Pickup Order
- 319Terminal Information
- 322Terminal Operations and Intermodal Ramp Activity
- 323Vessel Schedule and Itinerary (Ocean)
- 324Vessel Stow Plan (Ocean)
- 325Consolidation of Goods In Container
- 326Consignment Summary List
- 350Customs Status Information
- 352Customs Carrier General Order Status
- 353Customs Events Advisory Details
- 354Customs Automated Manifest Archive Status
- 355Customs Acceptance/Rejection
- 356Customs Permit to Transfer Request
- 357Customs In-Bond Information
- 358Customs Consist Information
- 359Customs Customer Profile Management
- 361Carrier Interchange Agreement (Ocean)
- 362Cargo Insurance Advice of Shipment
- 404Rail Carrier Shipment Information
- 410Rail Carrier Freight Details and Invoice
- 412Trailer or Container Repair Billing
- 414Rail Carhire Settlements
- 417Rail Carrier Waybill Interchange
- 418Rail Advance Interchange Consist
- 419Advance Car Disposition
- 420Car Handling Information
- 421Estimated Time of Arrival and Car Scheduling
- 422Equipment Order
- 423Rail Industrial Switch List
- 424Rail Carrier Services Settlement
- 425Rail Waybill Request
- 426Rail Revenue Waybill
- 429Railroad Retirement Activity
- 431Railroad Station Master File
- 432Rail Deprescription
- 433Railroad Reciprocal Switch File
- 434Railroad Mark Register Update Activity
- 435Standard Transportation Commodity Code Master
- 436Locomotive Information
- 437Railroad Junctions and Interchanges Activity
- 440Shipment Weights
- 451Railroad Event Report
- 452Railroad Problem Log Inquiry or Advice
- 453Railroad Service Commitment Advice
- 455Railroad Parameter Trace Registration
- 456Railroad Equipment Inquiry or Advice
- 460Railroad Price Distribution Request or Response
- 463Rail Rate Reply
- 466Rate Request
- 468Rate Docket Journal Log
- 470Railroad Clearance
- 475Rail Route File Maintenance
- 485Ratemaking Action
- 486Rate Docket Expiration
- 490Rate Group Definition
- 492Miscellaneous Rates
- 494Rail Scale Rates
- 500Medical Event Reporting
- 501Vendor Performance Review
- 503Pricing History
- 504Clauses and Provisions
- 511Requisition
- 517Material Obligation Validation
- 521Income or Asset Offset
- 527Material Due-In and Receipt
- 536Logistics Reassignment
- 540Notice of Employment Status
- 561Contract Abstract
- 567Contract Completion Status
- 568Contract Payment Management Report
- 601Customs Export Shipment Information
- 603Transportation Equipment Registration
- 620Excavation Communication
- 625Well Information
- 650Maintenance Service Order
- 715Intermodal Group Loading Plan
- 753Request for Routing Instructions
- 754Routing Instructions
- 805Contract Pricing Proposal
- 806Project Schedule Reporting
- 810Invoice
- 811Consolidated Service Invoice/Statement
- 812Credit/Debit Adjustment
- 813Electronic Filing of Tax Return Data
- 814General Request, Response or Confirmation
- 815Cryptographic Service Message
- 816Organizational Relationships
- 818Commission Sales Report
- 819Joint Interest Billing and Operating Expense Statement
- 820Payment Order/Remittance Advice
- 821Financial Information Reporting
- 822Account Analysis
- 823Lockbox
- 824Application Advice
- 826Tax Information Exchange
- 827Financial Return Notice
- 828Debit Authorization
- 829Payment Cancellation Request
- 830Planning Schedule with Release Capability
- 831Application Control Totals
- 832Price/Sales Catalog
- 833Mortgage Credit Report Order
- 834Benefit Enrollment and Maintenance
- 835Health Care Claim Payment/Advice
- 836Procurement Notices
- 837Health Care Claim
- 838Trading Partner Profile
- 839Project Cost Reporting
- 840Request for Quotation
- 841Specifications/Technical Information
- 842Nonconformance Report
- 843Response to Request for Quotation
- 844Product Transfer Account Adjustment
- 845Price Authorization Acknowledgment/Status
- 846Inventory Inquiry/Advice
- 847Material Claim
- 848Material Safety Data Sheet
- 849Response to Product Transfer Account Adjustment
- 850Purchase Order
- 851Asset Schedule
- 852Product Activity Data
- 853Routing and Carrier Instruction
- 854Shipment Delivery Discrepancy Information
- 855Purchase Order Acknowledgment
- 856Ship Notice/Manifest
- 857Shipment and Billing Notice
- 858Shipment Information
- 859Freight Invoice
- 860Purchase Order Change Request - Buyer Initiated
- 861Receiving Advice/Acceptance Certificate
- 862Shipping Schedule
- 863Report of Test Results
- 864Text Message
- 865Purchase Order Change Acknowledgment/Request - Seller Initiated
- 866Production Sequence
- 867Product Transfer and Resale Report
- 868Electronic Form Structure
- 869Order Status Inquiry
- 870Order Status Report
- 871Component Parts Content
- 872Residential Mortgage Insurance Application
- 873Commodity Movement Services
- 874Commodity Movement Services Response
- 875Grocery Products Purchase Order
- 876Grocery Products Purchase Order Change
- 877Manufacturer Coupon Family Code Structure
- 878Product Authorization/De-authorization
- 879Price Information
- 880Grocery Products Invoice
- 881Manufacturer Coupon Redemption Detail
- 882Direct Store Delivery Summary Information
- 883Market Development Fund Allocation
- 884Market Development Fund Settlement
- 885Retail Account Characteristics
- 886Customer Call Reporting
- 887Coupon Notification
- 888Item Maintenance
- 889Promotion Announcement
- 890Contract & Rebate Management Transaction
- 891Deduction Research Report
- 893Item Information Request
- 894Delivery/Return Base Record
- 895Delivery/Return Acknowledgment or Adjustment
- 896Product Dimension Maintenance
- 920Loss or Damage Claim - General Commodities
- 924Loss or Damage Claim - Motor Vehicle
- 925Claim Tracer
- 926Claim Status Report and Tracer Reply
- 928Automotive Inspection Detail
- 940Warehouse Shipping Order
- 943Warehouse Stock Transfer Shipment Advice
- 944Warehouse Stock Transfer Receipt Advice
- 945Warehouse Shipping Advice
- 947Warehouse Inventory Adjustment Advice
- 980Functional Group Totals
- 990Response to a Load Tender
- 993Secured Receipt or Acknowledgment
- 996File Transfer
- 997Functional Acknowledgment
- 998Set Cancellation
- 999Implementation Acknowledgment
