Question

Can you provide a sample X12 837 Claim file with the fields identified?

Answer 1

ISA*00* *00* *ZZ*SUBMITTER ID *ZZ*RECEIVER ID *YYMMDD*HHMM*^*00501*INTERCHANGE CONTROL NUMBER*1*T*:~

GS*HC*SENDER CODE*RECEIVER CODE*YYMMDD*HHMM*GROUP CONTROL NUMBER*X*005010X222A1~

ST*837*TRANSACTION SET CONTROL NUMBER*005010X222A1~

BHT*0019*00*BATCH CONTROL NUMBER*YYMMDD*HHMM*CH~

NM1*41*2*SUBMITTER NAME*****46*SUBMITTER ID~ PER*IC*CONTACT NAME*TE*CONTACT PHONE NUMBER~

NM1*40*2*RECEIVER NAME*****46*RECEIVER ID~

HL*1**20*1~

NM1*85*2*BILLING PROVIDER NAME*****XX*NPI NUMBER~

N3*BILLING PROVIDER ADDRESS~

N4*BILLING PROVIDER CITY*BILLING PROVIDER STATE*BILLING PROVIDER ZIP~

REF*EI*TAX ID NUMBER~

HL*2*1*22*0~

SBR*S*18*GROUP NUMBER*GROUP NAME*INSURED TYPE CODE*PATIENT RELATIONSHIP CODE*****CI~

NM1*IL*1*INSURED LAST NAME*INSURED FIRST NAME****MI*INSURED ID~

N3*INSURED ADDRESS~

N4*INSURED CITY*INSURED STATE*INSURED ZIP~

DMG*D8*INSURED BIRTH DATE*INSURED GENDER~

NM1*PR*2*PAYER NAME*****PI*PAYER ID~

N3*PAYER ADDRESS~

N4*PAYER CITY*PAYER STATE*PAYER ZIP~

CLM*CLAIM ID*TOTAL CHARGE AMOUNT***PLACE OF SERVICE:CLAIM FREQUENCY CODE:CLINIC TYPE CODE*YES/NO*YES/NO*YES/NO*I~

HI*BK:PRINCIPAL DIAGNOSIS CODE*BF:ADDITIONAL DIAGNOSIS CODE~

LX*1~

SV1*HC:PROCEDURE CODE*CHARGE AMOUNT*UNITS*1*PROVIDER CHARGE INDICATOR**REVENUE CODE~

DTP*472*D8*SERVICE DATE~

LX*2~

SV1*HC:PROCEDURE CODE*CHARGE AMOUNT*UNITS*1*PROVIDER CHARGE INDICATOR**REVENUE CODE~

DTP*472*D8*SERVICE DATE~

SE*NUMBER OF INCLUDED SEGMENTS*TRANSACTION SET CONTROL NUMBER~

GE*NUMBER OF TRANSACTION SETS*GROUP CONTROL NUMBER~

IEA*NUMBER OF INCLUDED FUNCTIONAL GROUPS*INTERCHANGE CONTROL NUMBER~

Answer 2

Explanation of the Fields

• ISA Segment: Interchange Control Header

  • ISA*00* *00* *ZZ*SUBMITTER ID *ZZ*RECEIVER ID *YYMMDD*HHMM*^*00501*INTERCHANGE CONTROL NUMBER*1*T*:~

• GS Segment: Functional Group Header

  • GS*HC*SENDER CODE*RECEIVER CODE*YYMMDD*HHMM*GROUP CONTROL NUMBER*X*005010X222A1~

• ST Segment: Transaction Set Header

  • ST*837*TRANSACTION SET CONTROL NUMBER*005010X222A1~

• BHT Segment: Beginning of Hierarchical Transaction

  • BHT*0019*00*BATCH CONTROL NUMBER*YYMMDD*HHMM*CH~

• NM1 Segment: Individual or Organizational Name

  • Submitter Name: NM1*41*2*SUBMITTER NAME*****46*SUBMITTER ID~
  • Receiver Name: NM1*40*2*RECEIVER NAME*****46*RECEIVER ID~

• PER Segment: Administrative Communications Contact

  • PER*IC*CONTACT NAME*TE*CONTACT PHONE NUMBER~

• HL Segment: Hierarchical Level

  • Billing Provider HL: HL*1**20*1~
  • Subscriber HL: HL*2*1*22*0~

• NM1 Segment: Billing Provider Name

  • NM1*85*2*BILLING PROVIDER NAME*****XX*NPI NUMBER~

• N3 Segment: Billing Provider Address

  • N3*BILLING PROVIDER ADDRESS~

• N4 Segment: Billing Provider Location

  • N4*BILLING PROVIDER CITY*BILLING PROVIDER STATE*BILLING PROVIDER ZIP~

• REF Segment: Reference Identification

  • REF*EI*TAX ID NUMBER~

• SBR Segment: Subscriber Information

  • SBR*S*18*GROUP NUMBER*GROUP NAME*INSURED TYPE CODE*PATIENT RELATIONSHIP CODE*****CI~

• NM1 Segment: Subscriber Name

  • NM1*IL*1*INSURED LAST NAME*INSURED FIRST NAME****MI*INSURED ID~

• N3 Segment: Subscriber Address

  • N3*INSURED ADDRESS~

• N4 Segment: Subscriber Location

  • N4*INSURED CITY*INSURED STATE*INSURED ZIP~

• DMG Segment: Demographic Information

  • DMG*D8*INSURED BIRTH DATE*INSURED GENDER~

• NM1 Segment: Payer Name

  • NM1*PR*2*PAYER NAME*****PI*PAYER ID~

• N3 Segment: Payer Address

  • N3*PAYER ADDRESS~

• N4 Segment: Payer Location

  • N4*PAYER CITY*PAYER STATE*PAYER ZIP~

• CLM Segment: Claim Information

  • CLM*CLAIM ID*TOTAL CHARGE AMOUNT***PLACE OF SERVICE:CLAIM FREQUENCY CODE:CLINIC TYPE CODE*YES/NO*YES/NO*YES/NO*I~

• HI Segment: Health Care Diagnosis Code

  • HI*BK:PRINCIPAL DIAGNOSIS CODE*BF:ADDITIONAL DIAGNOSIS CODE~

• LX Segment: Service Line Number

  • First Service Line: LX*1~
  • Second Service Line: LX*2~

• SV1 Segment: Professional Service

  • First Service Line: SV1*HC:PROCEDURE CODE*CHARGE AMOUNT*UNITS*1*PROVIDER CHARGE INDICATOR**REVENUE CODE~
  • Second Service Line: SV1*HC:PROCEDURE CODE*CHARGE AMOUNT*UNITS*1*PROVIDER CHARGE INDICATOR**REVENUE CODE~

• DTP Segment: Date or Time Period

  • First Service Line: DTP*472*D8*SERVICE DATE~
  • Second Service Line: DTP*472*D8*SERVICE DATE~

• SE Segment: Transaction Set Trailer

  • SE*NUMBER OF INCLUDED SEGMENTS*TRANSACTION SET CONTROL NUMBER~

• GE Segment: Functional Group Trailer

  • GE*NUMBER OF TRANSACTION SETS*GROUP CONTROL NUMBER~

• IEA Segment: Interchange Control Trailer

  • IEA*NUMBER OF INCLUDED FUNCTIONAL GROUPS*INTERCHANGE CONTROL NUMBER~

This structure provides a clear understanding of the purpose of each segment and field within an X12 837 Health Care Claim message.

Answer 3

Example of Usage:

In an 837 Health Care Claim message, you might have:

• ISA and GS segments at the beginning of the interchange.
• ST segment for each transaction set (e.g., one per claim).
• BHT segment to specify details about each claim.
• NM1 segments for the submitter, receiver, billing provider, insured, and payer.
• HL segments to outline the hierarchical levels (e.g., billing provider, subscriber).
• SBR segment for each subscriber.
• CLM segment for each claim submitted.
• HI segments for each diagnosis code associated with the claim.
• LX, SV1, and DTP segments repeated for each service line within a claim.