837 101 Tutorial

Background

The ANSI ASC X12 837 is the claim/encounter format. It is important to note all X12 formats are messaging standards developed for the sole purpose of transmitting data between two entities referred to as trading partners in the HIPAA legislation. The organization of each ANSI ASC X12 standard is determined by well-defined business needs. Specific uses of each standard are defined in implementation guides. There are currently five (5) implementation guides written for the 837 claim / encounter standard.

Current 837 Implementation Guides

• Institutional Claim Guide (X096) - This guide is named in the HIPAA legislation and represents the 4010A1 (October 1997) version of the standard. In 2012 the 5010 version (October 2003) of the ANSI X12 Standard will replace the current version. The new version of the Institutional Claim guides is named X223.


• Dental Claim Guide (X097) - This guide is named in the HIPAA legislation and represents the 4010A1 (October 1997) version of the standard. In 2012 the 5010 (October 2003) version of the ANSI X12 Standard will replace the current version. The new version of the Institutional Claim guides is named X224.
  
• Professional Claim Guide (X098) - This guide is named in the HIPAA legislation and represents the 4010A1 (October 1997) version of the standard. In 2012 the 5010 version (October 2003) of the ANSI X12 Standard will replace the current version. The new version of the Institutional Claim guides is named X222.
  
• Health Care Service Data Reporting Guide (HCSDRG) is NOT named in the HIPAA legislation, but has been developed along with the other 837 guides. The 5010 version (October 2003) is the most current approved ANSI standard. This new version of the HCSDRG is named X225. This updated the 4050 (October 2001) version, which was named X156.

Note: The number in parenthesis is the Implementation Guide number assigned by Washington Publishing Company, which has the contract to publish ANSI ASC X12 implementation guides. It is also important to note that no substantive changes have been made in the structure of the 837 between versions.

Highlights of the 837 Organizational Structure

The 837 standard is organized as described below. Each implementation guide uses this structure, but there will be some differences based on the business needs being met by each respective implementation. It is important to note that all the implementations are restricted to the structure defined in the 837 standard itself.

• Housekeeping information about the 837 Transaction Set reported.
  • HEADER Loop
  • Repeats 1 time
• The submitter of the information is identified with necessary contact information.
  • Loop ID - 1000
  • Repeats 1 time
• The receiver of the information is identified with necessary contact information.
  • Loop ID - 1000
  • Repeats 1 time
• The provider of health care services is identified.
  • Loop ID - 2000
  • Repeats more than 1 time to allow submissions with information from multiple providers
  • Each provider is labeled to enable identifying the relationship between patients receiving care from that provider later in the structure.
• For each provider of health care services the patients receiving care are identified.
  • Loop ID - 2010
  • Repeats more than 1 time to allow submissions with information from multiple patients
  • A relationship is established between the provider of the services and the patient receiving services from that provider

Note: Because one of the main functions of the 837 is for payment of health care claims, the format supports reporting of the subscriber of health insurance when that subscriber is NOT the patient.

• For each patient a variety of supporting information is reported including but not restricted to demographic, identifying, claim related dates, diagnosis, and physician data.
  • Loop ID - 2300
  • Repeats up to 100 times to allow for multiple stays for this patient
• For each patient the potential payers for that service are identified.
  • Loop ID - 2320
  • Repeats up to 10 times to allow for the reporting of multiple payers for that health care service.
• For each patient the services provided along with associated charges are identified.
  • Loop ID - 2400
  • Repeats more than 1 to allow for the reporting of multiple health care services for each patient.

Important ANSI ASC X12 Syntax Concepts

• Data in ANSI ASC X12 standards is organized into segments. Each segment contains multiple data elements, which are classified as simple or composite. Data elements may contain coded information maintained by ANSI ASC X12 (Internal code lists) or by outside organizations (External code lists) as well as qualified information.
• Multiple occurrences of information is supported by the looping structure in the 837 claim/encounter standard. Parent/Child relationships between loops is also supported in the 837 standards by use of Hierarchical Levels (HL segments).
• Segments and data elements in each loop are defined as either required or situational in each implementation guide. A statement of the usage of each situational data element is defined in the implementation guide.

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