HIPAA 5010 rules for the electronic transmission of healthcare claim information specify the EDI 837 Healthcare Claim transaction set and format. These HIPAA 5010 837 transaction sets are utilised for professionals, dentistry offices, and institutions: 837 Q1, 837 Q2, and 837 Q3. Payers received the correct 837 transaction set from providers. You can send encounter data, billing information for healthcare claims, or both using this transaction set.
One who pays claims, manages an insurance benefit or product, or does both is referred to as the payer. The payer might be a government agency (Medicare, Medicaid, etc.), an insurance company, an HMO, a PPO, a preferred provider organisation, or a third party administrator (TPA) or third party organisation (TPO) that has a contract with one of those organisations.
837s can be sent by providers directly to payers or through clearinghouses. When coordination of benefits is necessary, the EDI 837 transaction set can also be used to send healthcare claims and billing payment information between payers with various payment obligations. Additionally, payers and regulatory bodies may utilise it.
The EDI 835 transaction set is used by health insurers and other payers to communicate payments and information about benefit coordination to providers.
The following are the main components of the claim information for a single patient-provider interaction: patient descriptors, the condition for which care was provided, the services rendered, and the cost(s) of this care.
You can transmit encounter information, billing information for healthcare claims, or both using EDI 837 Q3 Institutional Claim. When coordination of benefits is necessary, the EDI 837 Q3 can also be used to transmit healthcare claims and billing payment information between payers with different payment responsibilities or between payers and regulatory agencies to track the provision, billing, and/or payment of healthcare services within a particular healthcare/insurance industry segment.
A regulatory agency is a body mandated by law or regulation to manage and oversee a statutory benefits programme or a particular area of the healthcare or insurance industries.
Payers receive the EDI 837 Healthcare Claim from providers or other third parties. Attachments may also be delivered with the optional EDI 275 Additional Patient Information (Unsolicited). An EDI 999 Implementation Acknowledgement is returned by the payer or clearinghouse system to acknowledge receipt of the incoming EDI 837 Healthcare Claim. All claims received in the payer's pre-processing system may be acknowledged by the payer through an EDI 277 Claim Acknowledgement.
To find out the claim's status, an EDI 276 Claim Status Request is submitted. The payer transmits the EDI 277 Claim Status Response. An EDI 277 Request for Additional Information can also be sent by the payer. In response, the EDI 275 Additional Information (Solicited) is delivered, which can have attachments for patient records.
The payer delivers the EDI 277 Claim Pending Status Information once the claim's components have been confirmed. Explanations of Benefits (EOBs) and payments to healthcare providers are handled using the EDI 835 Claim Payment/Advice. The payment to the claim is tracked and detailed using the EDI 835.
X12 HIPAA 837I Sample File
ISA*00* *00* *ZZ*1234567 *ZZ*11111 *170508*1141*^*00501*000000101*1*P*:~
GS*HC*XXXXXXX*XXXXX*20170617*1741*101*X*005010X223A2~
ST*837*987654*005010X223A2~
BHT*0019*00*0123*19960918*0932*CH~
NM1*41*2*JONES HOSPITAL*****46*12345~
PER*IC*JANE DOE*TE*9005555555~
NM1*40*2*MEDICARE*****46*00120~
HL*1**20*1~
PRV*BI*PXC*203BA0200N~
NM1*85*2*JONES HOSPITAL*****XX*9876540809~
N3*225 MAIN STREET BARKLEY BUILDING~
N4*CENTERVILLE*PA*17111~
REF*EI*567891234~
PER*IC*CONNIE*TE*3055551234~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*DOE*JOHN*T***MI*030005074A~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
DMG*D8*19261111*M~
NM1*PR*2*MEDICARE B*****PI*00435~
REF*G2*330127~
CLM*756048Q*89.93**14:A:1*A*Y*Y~
DTP*434*RD8*19960911~
CL1*3**01~
HI*BK:3669~
HI*BF:4019*BF:79431~
HI*BH:A1:D8:19261111*BH:A2:D8:19911101*BH:B1:D8:19261111*BH:B2:D8:19870101~
HI*BE:A2:::15.31~
HI*BG:09~
NM1*71*1*JONES*JOHN*J~
REF*1G*B99937~
SBR*S*01*351630*STATE TEACHERS*****CI~
OI***Y***Y~
NM1*IL*1*DOE*JANE*S***MI*222004433~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
NM1*PR*2*STATE TEACHERS*****PI*1135~
LX*1~
SV2*0305*HC:85025*13.39*UN*1~
DTP*472*D8*19960911~
LX*2~
SV2*0730*HC:93005*76.54*UN*3~
DTP*472*D8*19960911~
SE*42*987654~
GE*1*101~
GS*HC*XXXXXXX*XXXXX*20170617*1741*101*X*005010X223A2~
ST*837*987654*005010X223A2~
BHT*0019*00*0123*19960918*0932*CH~
NM1*41*2*JONES HOSPITAL*****46*12345~
PER*IC*JANE DOE*TE*9005555555~
NM1*40*2*MEDICARE*****46*00120~
HL*1**20*1~
PRV*BI*PXC*203BA0200N~
NM1*85*2*JONES HOSPITAL*****XX*9876540809~
N3*225 MAIN STREET BARKLEY BUILDING~
N4*CENTERVILLE*PA*17111~
REF*EI*567891234~
PER*IC*CONNIE*TE*3055551234~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*DOE*JOHN*T***MI*030005074A~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
DMG*D8*19261111*M~
NM1*PR*2*MEDICARE B*****PI*00435~
REF*G2*330127~
CLM*756048Q*89.93**14:A:1*A*Y*Y~
DTP*434*RD8*19960911~
CL1*3**01~
HI*BK:3669~
HI*BF:4019*BF:79431~
HI*BH:A1:D8:19261111*BH:A2:D8:19911101*BH:B1:D8:19261111*BH:B2:D8:19870101~
HI*BE:A2:::15.31~
HI*BG:09~
NM1*71*1*JONES*JOHN*J~
REF*1G*B99937~
SBR*S*01*351630*STATE TEACHERS*****CI~
OI***Y***Y~
NM1*IL*1*DOE*JANE*S***MI*222004433~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
NM1*PR*2*STATE TEACHERS*****PI*1135~
LX*1~
SV2*0305*HC:85025*13.39*UN*1~
DTP*472*D8*19960911~
LX*2~
SV2*0730*HC:93005*76.54*UN*3~
DTP*472*D8*19960911~
SE*42*987654~
GE*1*101~
IEA*1*000000101~
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