By | 2019-10-09T12:41:41+00:00 October 9th, 2019|

What is an EDI 837 Health Care Claim: Professional?

The EDI 837 Health Care Claim transaction set is used by healthcare service providers for submitting claim billing details, encounter information, or both. An EDI 837 document is organized into data elements and segments. These segments contain the following information:

  • The healthcare provider details
  • The patient’s insurance plan
  • Services provided
  • The cost of the treatment
  • The patient’s medical history

EDI X12 837 Health Care Claim: Professional Sample

The following example details the format of an EDI 837 document[1].

ISA*00* *00* *01*9012345720000 *01*9088877320000
*100816*1144*U*00200*000000031*0*T*:~
GS*HC*901234572000*908887732000*20100816*1615*31*X*005010X223A1~
ST*837*0034*005010X223A1~
BHT*0019*00*3920394930203*20100816*1615*CH~
NM1*41*2*HOWDEE HOSPITAL*****46*0123456789~
PER*IC*BETTY RUBBLE*TE*9195551111~
NM1*40*2*BCBSNC*****46*987654321~
HL*1**20*1~
NM1*85*2*HOWDEE HOSPITAL*****XX*1245011012~
N3*123 HOWDEE BLVD~
N4*DURHAM*NC*27701~
REF*EI*123456789~
PER*IC*WILMA RUBBLE*TE*9195551111*FX*6145551212~
HL*2*1*22*0~
SBR*P*18*XYZ1234567******BL~
NM1*IL*1*DOUGH*MARY****MI*24672148306~
N3*BOX 12312~
N4*DURHAM*NC*27715~
DMG*D8*19670807*F~
NM1*PR*2*BCBSNC*****PI*987654321~
CLM*2235057*200***13:A:1***A**Y*Y~
DTP*434*RD8*20100730-20100730~
CL1*1*9*01~
REF*F8*ASD0000123~
HI*BK:25000~
HI*BF:78901~
HI*BR:4491:D8:20100730~
HI*BH:41:D8:20100501*BH:27:D8:20100715*BH:33:D8:20100415*BH:C2:D8:20100410~
HI*BE:30:::20~
HI*BG:01~
NM1*71*1*SMITH*ELIZABETH*AL***34*243898989~
REF*1G*P97777~
LX*1~
SV2*0300*HC:81000*120*UN*1~
DTP*472*D8*20100730~
LX*2~
SV2*0320*HC:76092*50*UN*1~
DTP*472*D8*20100730~
LX*3~
SV2*0270*HC:J1120*30*UN*1~
DTP*472*D8*20100730~
SE*38*0034~
GE*1*30~
IEA*1*000000031~

Workflow for the Exchange of an EDI 837 Health Care Claim: Professional

One of the X12 transactions, EDI 837 is one of the commonly used healthcare transaction sets, which aids the transmission of claim information. This transaction set helps healthcare organizations ensure accurate, secure, and reliable claim processing.

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Astera EDIConnect is an enterprise-grade EDI solution that simplifies the process of sending and receiving EDI messages. Featuring a built-in EDI parser, validator, and transaction builder, AsteraEDIConnect makes the process of onboarding new partners and configuring their requirements quick and simple.

[1] https://www.bluecrossnc.com/sites/default/files/document/attachment/providers/public/pdfs/837_Institutional_5010_v3.4.pdf

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