837 Transaction Overview

Overview
This document is a synopsis of the 837 Transaction for Providers. It not intended to be a programming guide for creating the transaction set (please refer to the Companion Guides; see below, for programming information).
The 837 Health Care Transaction, established by the Health and Human Services agency (HHS), defines the computerized format and data contents of the standard health care claim transaction for use in the Electronic Data Interchange (EDI) environment. The 837 transaction is used to submit information for claim billing. Health care service providers may also use it for the exchange of information and coordination of benefits with multiple payers. Claims may be submitted to payers either directly or through a clearinghouse. Health care service providers include but are not limited to physicians, dentists, pharmacists, hospitals and other medical facilities or suppliers. Payers are third party entities that pay claims or administer insurance benefits or both. These include but are not limited to insurance agencies, health maintenance organizations (HMOs), preferred provider organizations (PPO) and government health care agencies (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.). They may also include entities such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups.
A. Transaction Types
There are three types of 837 transactions:
• Professional - Used by an individual professional or practitioner to bill for medical services
• Dental - Used by dentists to bill for dental services
• Institutional - Used by most non-person entities to bill for medical and medically related services
All share the same hierarchical data structure but have internal differences that accommodate the different billing needs of the three types. For instance, rate code information may only be submitted on an 837 Institutional claim.
B. Transaction Structure Overview
The 837 transaction is designed to transmit one or more claims for each Provider submitting claims. The hierarchy of the loops and segments allows for more efficient transfer of data, as information common to all levels of the claim is not repeated.
Information common to all levels of submitted claim
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• Provider’s Billing Information
• Subscriber Information
Information specific to a patient, may be repeated for multiple services or patients
• Patient Information
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• Claim level
• Claim Service Line Level
The 837 transaction also supports the Coordination of Benefits (COB) claim process. Additional repeated segments may be used at the claim and service line levels to transfer each payer’s adjudication information to subsequent payers.
This transaction is also recommended for submission of data for pre-paid managed care, referred to as capitated encounters. The capitated encounter data may be both informational (pre-paid - no payment expected) and a request for payment depending on the service(s) rendered.