Standard Layout (ASC X12 837 Professional)
Table 01: Transaction Set Header
ST / R / Transaction Set Header / ST / Maximum Use: 1 /Reference / Use / Name / Value / Comments
ST01 / R / Transaction Set Identification Code / 837 / Health Care Claim
ST02 / R / Transaction Set Control Number / Number / Must match value in SE02 Transaction Set Control Number. The number must be unique within the transaction set.
ST03 / O / Implementation Convention Reference / 005010X222A1 / 005010X222__ – 837 Professional Claim
Semantic Notes
· The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
· Specified functional group (GS-SE) and interchange (ISA-IEA) but can repeat in other groups and interchanges. Begins with 0001 and increments +1 for each subsequent ST within the GE. Resets back to 0001 with each new file.
Table 02: Begin Hierarchical Transaction
BHT / R / Begin Hierarchical Transaction / BHT / Maximum Use :1 /Reference / Use / Name / Value / Comments
BHT01 / R / Hierarchical Structure Code / 0019 / Information Source
BHT02 / R / Transaction Set Purpose Code / Valid Values: 00 ( Original), 18 (Reissue), 31 (Subrogation Demand)
BHT03 / R / Reference Identification / Number / User Defined; See Note 1
BHT04 / R / Date / CCYYMMDD / Format: CCYYMMDD File create date
BHT05 / R / Time / HHMM / Format: HHMM, HHMMSS, or HHMMSSD File create time
BHT06 / R / Transaction Type Code / RP / Valid Values: CH (Chargeable), RP (Reporting); See Note 2
Notes
· Must be filled in by the submitter. BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system.
· All encounter claims must have the value of BHT06 set to ‘RP’.
Table 03: Loop 1000A Submitter Name
1000A / R / Loop / Maximum Use: 1 /Reference / Use / Name / Value / Comments
NM1 / R / Submitter Name / NM1 / Maximum Use: 1
NM101 / R / Entity Identifier Code / 41 / Submitter
NM102 / R / Entity Type Qualifier / 2 / Valid Values: 1 (Person), 2 (Non-Person Entity)
NM103 / R / Name Last or Organization Name / Name / Submitter Last or Organization Name
NM104 / S / Name First / Submitter First Name
Required if NM102 = 1, else Leave Blank.
NM105 / S / Name Middle / Submitter Middle Name
Required if NM102=1 and needed to identify the individual, else Leave Blank.
NM106 / S / Name Prefix / Submitter Name Prefix
NM107 / S / Name Suffix / Submitter Name Suffix
Needed if NM102=1 and suffix is part of legal name, else Leave Blank.
NM108 / R / Identification Code Qualifier / 46 / Electronic Transmitter Identification Number (ETIN) established by trading partner agreement
NM109 / R / Identification Code / ID / Submitter Identifier assigned by Medicaid
NM110 / NU / Entity Relationship Code / Not Used , Leave Blank
NM111 / NU / Entity Identifier Code / Not Used , Leave Blank
NM112 / NU / Name Last or Organization Name / Not Used , Leave Blank
PER / R / Submitter EDI Contact Information / PER / Maximum Use: 2
PER01 / R / Contact Function Code / IC / Information Contact
PER02 / R / Name / Name / Submitter Contact Name
PER03 / R / Communication Number Qualifier / TE / Valid Values: ED (Electronic Data Interchange Address Number), EM (Electronic Mail), FX (Fax), TE (Phone)
PER04 / R / Communication Number / Number / Submitter Telephone Number
PER05 / S / Communication Number Qualifier / See PER03
PER06 / S / Communication Number / Submitter Address or Number
PER07 / NU / Communication Number Qualifier / Not Used , Leave Blank
PER08 / NU / Communication Number / Not Used , Leave Blank
PER09 / NU / Contact Inquiry Reference / Not Used , Leave Blank
Table 04: Loop 1000B Receiver Name
1000B / R / Loop / Maximum Use: 1 /Reference / Use / Name / Value / Comments
NM1 / R / Receiver Name / NM1 / Maximum Use: 1
NM101 / R / Entity Identifier Code / 40 / Receiver
NM102 / R / Entity Type Qualifier / 2 / Valid Values: 1 (Person), 2 (Non-Person Entity)
NM103 / R / Name Last or Organization Name / Name / Receiver Last or Organization Name
NM104 / NU / Name First / Not Used , Leave Blank
NM105 / NU / Name Middle / Not Used , Leave Blank
NM106 / NU / Name Prefix / Not Used , Leave Blank
NM107 / NU / Name Suffix / Not Used , Leave Blank
NM108 / R / Identification Code Qualifier / 46 / Electronic Transmitter ID Number (ETIN) established by trading partner agreement
NM109 / R / Identification Code / ID / Receiver Primary Identifier
NM110 / NU / Entity Relationship Code / Not Used , Leave Blank
NM111 / NU / Entity Identifier Code / Not Used , Leave Blank
NM112 / NU / Name Last or Organization Name / Not Used , Leave Blank
Table 05: Loop 2000A Billing Pay-To Provider
2000A / R / Loop / Maximum Use: > 1 /Reference / Use / Name / Value / Comments
HL / R / Billing/Pay-To Provider Hierarchical Level / HL / Maximum Use: 1
HL01 / R / Hierarchical ID Number / Number / Must begin with "1" and increment by one for each HL used. Only Numeric values are allowed.
HL02 / NU / Hierarchical Parent ID Number / Not Used , Leave Blank
HL03 / R / Hierarchical Level Code / 20 / Information Source
HL04 / R / Hierarchical Child Code / 1 / Valid Values: 1 (Additional Subordinate HL data segment in this hierarchical structure)
PRV / S / Billing/Pay-To Provider Specialty Information / PRV / Maximum Use: 1
PRV01 / R / Provider Code / BI / Valid Values: BI (Billing)
PRV02 / R / Reference Identification Qualifier / PXC / Valid Values: PXC (Health Care Provider Taxonomy Code)
PRV03 / R / Reference Identification / Provider Taxonomy Code / Provider Taxonomy Code
Required when adjudication is known to be impacted by taxonomy code and rendering provider is same entity as billing or pay-to provider, else if Loop 2310B is Not Used , Leave Blank.
PRV04 / NU / State or Province Code / Not Used , Leave Blank
PRV05 / NU / Provider Specialty Information / Not Used , Leave Blank
PRV06 / NU / Provider Organization Code / Not Used , Leave Blank
CUR / S / Foreign Currency Information / CUR / Maximum Use: 1
CUR01 / R / Entity Identifier Code / Valid Values: 85 (Billing Provider)
CUR02 / R / Currency Code / Standard ISO code for country
CUR03 / NU / Exchange Rate / Not Used , Leave Blank
CUR04 / NU / Entity Identifier Code / Not Used , Leave Blank
CUR05 / NU / Currency Code / Not Used , Leave Blank
CUR06 / NU / Currency Market/Exchange Code / Not Used , Leave Blank
CUR07 / NU / Date/Time Qualifier / Not Used , Leave Blank
CUR08 / NU / Date / Not Used , Leave Blank
CUR09 / NU / Time / Not Used , Leave Blank
CUR10 / NU / Date/Time Qualifier / Not Used , Leave Blank
CUR11 / NU / Date / Not Used , Leave Blank
CUR12 / NU / Time / Not Used , Leave Blank
CUR13 / NU / Date/Time Qualifier / Not Used , Leave Blank
CUR14 / NU / Date / Not Used , Leave Blank
CUR15 / NU / Time / Not Used , Leave Blank
CUR16 / NU / Date/Time Qualifier / Not Used , Leave Blank
CUR17 / NU / Date / Not Used , Leave Blank
CUR18 / NU / Time / Not Used , Leave Blank
CUR19 / NU / Date/Time Qualifier / Not Used , Leave Blank
CUR20 / NU / Date / Not Used , Leave Blank
CUR21 / NU / Time / Not Used , Leave Blank
Table 06: Loop 2010AA Billing Provider Name
2010AA / R / Loop / Maximum Use: 1 /Reference / Use / Name / Value / Comments
NM1 / R / Billing Provider Name / NM1 / Maximum Use: 1
NM101 / R / Entity Identifier Code / 85 / Billing Provider
NM102 / R / Entity Type Qualifier / 1 or 2 / Valid Values: 1 (Person), 2 (Non-Person Entity)
NM103 / R / Name Last or Organization Name / Name / Billing Provider Last or Organization Name
NM104 / S / Name First / Billing Provider First Name
Required if NM102=1, else Leave Blank
NM105 / S / Name Middle / Billing Provider Middle Name
Required if NM102=1 and needed to identify the individual, else Leave Blank.
NM106 / NU / Name Prefix / Not Used , Leave Blank
NM107 / S / Name Suffix / Billing Provider Name Suffix
Needed if NM102=1 and suffix is part of legal name, else Leave Blank.
NM108 / R / Identification Code Qualifier / XX / National Provider Identifier
NM109 / R / Identification Code / NPI / Billing Provider Identifier; Used in provider Matching Billing Provider's National Provider ID (NPI)
NM110 / NU / Entity Relationship Code / Not Used , Leave Blank
NM111 / NU / Entity Identifier Code / Not Used , Leave Blank
NM112 / NU / Last Name or Organization Name / Not Used , Leave Blank
N3 / R / Billing Provider Address / N3 / Maximum Use: 1
N301 / R / Address Information / Address / Billing Provider Address Line 1
N302 / S / Address Information / Billing Provider Address Line 2
N4 / R / Billing Provider City/State/ZIP Code / N4 / Maximum Use: 1
N401 / R / City Name / City / Billing Provider City Name
N402 / R / State or Province Code / State / Billing Provider State Code
N403 / R / Postal Code / Zip+4 / Billing Provider Postal Code (the full nine digit ZIP code must be provided)
N404 / S / Provider Country Code / Not Required, Leave Blank
N405 / NU / Location Qualifier / Not Used , Leave Blank
N406 / NU / Location Identifier / Not Used , Leave Blank
N407 / S / Country Subdivision Code / Not Required , Leave Blank
REF / R / Billing Provider Secondary ID / REF / Maximum Use: 1
REF01 / R / Reference Identification Qualifier / EI / Valid Values: EI (Employer's Id #), SY (Social Security #)
REF02 / R / Reference Identification / EIN / Billing Provider Tax Identification Number
REF03 / NU / Description / Not Used , Leave Blank
REF04 / NU / Reference Identifier / Not Used , Leave Blank
REF / S / Billing Provider UPIN/License Information / REF / Maximum Use: 2
REF01 / R / Reference Identification Qualifier / Valid Values: 0B (State License Number), 1G (Provider UPIN Number)
REF02 / R / Reference Identification / Billing Provider UPIN/License Number
REF03 / NU / Description / Not Used , Leave Blank /
REF04 / NU / Reference Identified / Not Used , Leave Blank
PER / S / Billing Provider Contact Information / PER / Maximum Use: 2
PER01 / R / Contact Function Code / Valid Values: IC (Information Contact)
PER02 / R / Name / Billing Provider Contact Name
PER03 / R / Communication Number Qualifier / Valid Values: EM (Electronic Mail), FX (Fax), TE (Telephone)
PER04 / R / Communication Number / Billing Provider Telephone Number
PER05 / S / Communication Number Qualifier / Valid Values: EM (Electronic Mail), EX(Telephone Extension), FX (Fax), TE(Telephone)
PER06 / S / Communication Number / Billing Provider Address or Number
PER07 / S / Communication Number Qualifier / Valid Values: EM (Electronic Mail), EX (Telephone Extension), FX (Fax), TE (Telephone)
PER08 / S / Communication Number / Billing Provider Address or Number
PER09 / NU / Contact Inquiry Reference / Not Used , Leave Blank
Table 07: Loop 2010AB Pay-To Provider Name
2010AB / R / Loop / Maximum Use: 1 /Reference / Use / Name / Value / Comments
NM1 / R / Pay-To Provider Name / NM1 / Maximum Use: 1
NM101 / R / Entity Identifier Code / 87 / Pay-to Provider
NM102 / R / Entity Type Qualifier / 1 or 2 / Valid Values: 1 (Person), 2 (Non-Person Entity)
NM103 / R / Name Last or Organization Name / Name / Pay-to Provider or Organization Name
NM104 / S / Name First / Pay-to Provider First Name
Required if NM102=1, else Leave Blank
NM105 / S / Name Middle / Pay-to Provider Middle Name
Required if NM102=1 and needed to identify the individual, else Leave Blank.
NM106 / NU / Name Prefix / Not Used , Leave Blank
NM107 / S / Name Suffix / Pay-to Provider Name Suffix
Needed if NM102=1 and suffix is part of legal name, else Leave Blank.
NM108 / R / Identification Code Qualifier / XX / National Provider Identifier
NM109 / R / Identification Code / NPI / Pay-to Provider Identifier; Used in provider Matching Pay-to Provider's National Provider ID (NPI)
NM110 / NU / Entity Relationship Code / Not Used , Leave Blank
NM111 / NU / Entity Identifier Code / Not Used , Leave Blank
NM112 / NU / Last Name or Organization Name / Not Used , Leave Blank
N3 / R / Pay-To Provider Address / N3 / Maximum Use: 1
N301 / R / Address Information / Address / Pay-to Provider Address Line 1
N302 / S / Address Information / Pay to Provider Address Line 2
N4 / R / Pay-To Provider City/State/ZIP Code / N4 / Maximum Use: 1
N401 / R / City Name / City / Pay-to Provider City Name
N402 / R / State or Province Code / State / Pay-to Provider State Code
N403 / R / Postal Code / Zip+4 / Pay-to Provider Postal Code (the full nine digit ZIP code must be provided)
N404 / S / Country Code / Not Required, Leave Blank
N405 / NU / Location Qualifier / Not Used , Leave Blank
N406 / NU / Location Identifier / Not Used , Leave Blank
N407 / S / Country Subdivision Code / Not Required, Leave Blank
Table 08: Loop 2010AC Pay-To Plan
2010AC / S / Loop / Maximum Use: 1 /Reference / Use / Name / Value / Comments
NM1 / S / Pay-To Plan Name / NM1 / Maximum Use: 1
NM101 / R / Entity Identifier Code / Valid Values: PE (Payee)
NM102 / R / Entity Type Qualifier / Valid Values: 2 (Non-Person Entity)
NM103 / R / Name Last or Organization Name / Organization Name