EDI 837

The EDI 837 transaction set is an electronic version of a paper Healthcare Claim Payment and Remittance Advice that complies with the ANSI X12 EDI specification. The EDI Health Care Claim Transaction set (EDI 837) is used in HIPAA EDI transactions to submit health care claim billing information, encounter information, or both. This transaction set is sent by a health care provider to an insurance payer such as an insurance company, health care professional (HMO), preferred provider organization (PPO) or a government agency (Medicaid, Medicare etc.). Providers may send 837s either directly or via intermediary billers and claims clearing houses. Information on coordinated benefits and payments are sent back to providers using the EDI 835 transaction set by Health insurers and other payers. After March 31, 2012, the 5010 standards divided the 837 transaction sets into three groups as follows: 837I– for institutions, 837P for professionals and 837 D – for dental practices.

The claim information includes the following data for single care encounter between a provider and a patient:

• Patient Descriptors
• Condition for which treatment was provided to patient
• Services Provided
• The Cost of Treatment

Other EDI transaction sets related to EDI 837 are:

• EDI 204 - Motor Carrier Load Tender
• EDI 210 - Motor Carrier Freight Details & Invoice
• EDI 214 - Transportation Carrier Shipment Status Message
• EDI 753 - Request for Routing Instructions
• EDI 810 - Invoice
• EDI 812 - Credit / Debit Adjustment
• EDI 820 - Payment or Order Remittance
• EDI 832 - Price/Sales Catalog
• EDI 830 - Planning Schedule with Release Capability
• EDI 835 - Health Care Claim Payment/Advice
• EDI 846 - Inventory Inquiry
• EDI 850 - Purchase Order
• EDI 855 - Purchase Order Acknowledgement
• EDI 860 - Purchase Order Change Request
• EDI 867 - Product Transfer and Resale Report File Format
• EDI 870 - Order Status Report
• EDI 875 - Grocery Products Purchase Order
• EDI 990 - Response to a Load Tender
• EDI 997 - Functional Acknowledgment