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Dummy’s Guide to the ANSI 837. And Now That I’ve Seen The IG. By: Cynthia Korman. 09/25/2003. Professional Claims - The 837P. For use by: Physicians (Hospital and Office-based services) Behavioral Health clinicians Ambulance Claims Some Home Health And more...

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Dummy s guide to the ansi 837 l.jpg

Dummy’s Guide to the ANSI 837

And Now That I’ve Seen The IG...

By: Cynthia Korman


Professional claims the 837p l.jpg
Professional Claims - The 837P

For use by:

  • Physicians (Hospital and Office-based services)

  • Behavioral Health clinicians

  • Ambulance Claims

  • Some Home Health

  • And more...

    If you’d file a paper HCFA 1500 or electronic NSF file, chances are you’ll file an 837P, not an 837I. Payer Companion Documents should tell you if that’s not true

Institutional claims the 837i l.jpg
Institutional Claims - The 837I

For use by:

  • Hospital inpatient and outpatient claims

  • Long Term Care claims

  • Some Home Health

  • And more...

    If you’d file a paper UB92 or earlier version of the 837I, chances are you’ll file an 837I, not an 837P. Payer Companion Documents should tell you if that’s not true

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837 Standards Maintenance Process

  • X12N Workgroups

  • 837 4010A1 is the standard as of 10/16/03 nationally - addenda page replacements

  • Per the HIPAA legislation

    • final standards cannot be published more frequently than once every 12 months

    • each update needs 180 days of lead time before it’s effective

  • Code Set Maintenance Organizations

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Claim File (837) Overview

  • Header Info - technical detail

  • Billing/Pay-to Provider info

  • Subscriber/Payer info

  • Claim info, including:

    • Patient demographics if patient & subscriber differ

    • Claim and Service Line detail

    • Coordination of Benefits info

    • Repricing info

      A “claim” is something that relates to one patient. It’s not a file of episodes of care for multiple patients: that would be a claim file

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The Importance of HL Segments

If you are or will be responsible for reading X12 files, for debugging purposes or denials management purposes or for any other purposes, you must understand how HLs work.

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How HLs Work

HL Segments are what properly connect groups of information in X12 files.

HL * 4 * 3 * 23 * 0

Code telling HL Type

HL Counter

Child HL? 1=Yes 0=No

Segment Name

Pointer to Parent HL

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Healthcare Claim File - HL Use

The bill from a Pediatrician’s Office or a hospital’s mater- nity floor can easily look like this when it gets to X12 format...


Other Segments


Other Segments


Other Segments


Other Segments


Other Segments


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Claim Data Requirements

  • Every Payer Must Accept the Data called for in the standard - can ignore what they don’t need

  • Claim Submitter’s Identifier - CLM01

    Tracks a claim from creation through payment - new for many provider information systems, look for itSome call itPatient Account Number, but be careful with that.

    Maximum length 20 characters

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Claim Data Requirements

  • The standard requires new data capture - in some cases whether or not it is needed for adjudication

    • ex 1: 837P, Patient Weight - Required on

      • 1) claims/encounters involving epoetin for patients on dialysis

      • 2) Medicare DMERC CMN 02.03 and 10.02

      • It’s got to be in pounds, not grams

    • ex 2: 837P Mammography Certification Number - “required when mammography services are rendered by a certified mammography provider”

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Claim Data Requirements

  • Code Sets

    • Internal - Changed (Patient Relationship to subscriber, 837I and 837P), Unchanged (837I Admission Codes), and New (Date/Time Qualifiers)

    • External - Changed (HCPCS, no more III), Unchanged (ICD-9s, CPTs, HCPCS I and II) , and New (Provider Taxonomy Code, Claim Adjustment Reason Codes)

      IG Data Element Descriptions, and IG Appendix C tell you the code sets, or where to find them. Some externals available at www.wpc-edi.com (free)

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Ya’ Gotta Love The Addenda

  • 4010A1 (004010X098A1 and 004010X096A1)

  • 837P Date of Death

    • Required if Patient is Known to be Deceased

      . . . AND

      the Date of Death is available to the Provider Billing System

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837 Simplified


Claim Data Requirements from the English Perspective

Healthcare English...

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837 Simplified





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Useful url’s

  • NJ Shore - www.njshore.org - free

  • Implementation Guides and Addenda - www.wpc-edi.com - free

  • WEDI - www.wedi.org/snip - free

  • Code Set Update Requests - Code Set maintenance organizations - http://www.wedi.org/snip, click on “Other HIPAA Resources/General Info/Professional Associations and Standards Organizations”

  • CMS HIPAA resources - www.cms.gov/hipaa/hipaa2 - free

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In Closing...

We’re all in Glass Houses

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And in closing...

Don’t lose sight of the forest because of the trees

Don’t forget that we all need administrative simplification in healthcare - this is how we’ll get there

Thank you

Strategic System Solutions, LLC

973 394-9529