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The 837 Transaction Set
The 837 transaction set can be used to submit health care claim billing information, encountered
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. This is mainly used 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 the purpose of this standard, providers of health care products or services may
force
entities such as physicians, hospitals and other medical facilities or suppliers,
dentists, and pharmacies, and entities providing medical information to
also 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, for administering and monitoring a statutory
benefits program or a specific health care/insurance industry segment.
One 837 can contain many claims from different providers all sent to one payer.
Each 837 has one area used to describe submitters and receivers of the claims called Table
One. It is the first part of the 837
set and only deals with information about those who
have sent or received the claims in the rest of the 837. There is a second area that
contains only claims related information known as Table Two.
Table One
Table 1 can be used to document those entities that have been a party and the ultimate
payer of the claim. When intermediary organizations such as billing services, claims
submission vendors, claims clearinghouses and Preferred Provider Organizations have
"opened the envelope" to add data or to reformat the claim, they can add
identification information in this area of the 837.
Table Two
Table 2 is used to send claims data. It can contain claims from one or many
providers. Claims are grouped in table 2 by "billing providers," so a
package of claims submission vendors will be in one 837. Each billing provider can send one
or many claims for each subscriber (insured), and claims can be sent for one or more
patients per subscriber. There are numerous types of claims that can be sent in an
837 for inpatient care (UB82 or UB92), outpatient care (HCFA 1500), dental, vision, drug,
durable medical equipment, and other kinds of care.
Looping Structure of the 837
The looping structure of the 837 in different versions of X12 varies significantly.
Version 3051, which is used in our example, has five major nested loops - PRV, SBR,
PAT, CLM, and LX, as shown below:
Submitted and Receiver Loop
1000
Billing Provider Loop
2000
Billing and Pay-to Provider Loop
2010
Subscriber information
Loop 2100
Subscriber's School and Employer
2110
Patient Information Loop
2200
Information about Patient
2210
Claim Loop
2300
Provider Information Loop
2310
Service Loop
2400
Drug Service Information Loop
2410
Service Level Provider
2420
Other Payer Data
2500
Looping Structure of the 837 (4010)
Submitted and Receiver Loop
1000
Billing Provider Loop
2000
Billing and Pay-to Provider Loop
2010
Claim Loop
2300
Plan Certification Loop
2305
Provider Information Loop
2310
Subscriber School and Employer
2320
Service
Loop 2400
Price Information Loop
2410
Provider Information Loop
2420
Service Line Adjudication Loop
2430
Data Relationship between 837 and 835
One 835 transaction can account for claims submitted using multiple 837
transactions. The Claim Submitter's Identifier reported in the claim within the 837 is
returned in the 835 transaction for tracking purposes. The Claim Submitter's Identifier is
located in the 837 in segment CLM, position 01. In the 835, the Claim Submitter's
Identifier is in segment CLP, position 01. Those two identifiers have to match, if these
two transaction sets are related.
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