EDI 837 Health Care Claim: Professional

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.  It is sent by a healthcare provider, such as a primary care physician (PCP) or a hospital, to an insurer.

This healthcare EDI claim is organized into data elements and segments. These segments contain the following information:

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

Benefits of Using an EDI 837 Transaction Set

It is easier for insurance companies to process digitized healthcare claims compared to paper-based claims. Manually handling claims is time-consuming and expensive, which leads to delays in administering patient care and reimbursement. EDI systems enable insurers to automate this, leading to reductions in processing costs of up to 30%.

Furthermore, EDI claims are a secure medium for exchanging sensitive patient information in accordance with HIPAA regulations.

EDI X12 837 Health Care Claim: Professional Sample

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~

There are multiple types of an EDI 837 document:

• EDI 837D: used for dental care
• EDI 837P: used for administering outpatient care
• EDI 837I: used for institutional care

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

One of the X12 transactions, 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. Once an 837 claim is received, insurers send back an EDI 835 transaction set that outlines the payment information and whether the payment is made or denied.

Automate EDI transactions with Astera EDIConnect

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