837I Institutional Claim CSV Columns

Claim

Loop: 2300, Segment: CLM CSV Example Interactive Example Open API Schema

Name	Description	Type	EDI Element
id	Unique payment identifier assigned by the converter	String
transactionType	Transaction set identifier code	String	ST01
fileName	Converted X12 EDI file name	String
transactionControlNumber	Transaction set control number	String	ST02
transactionSetPurposeCode	Transaction set purpose code	String	BHT02
originatorApplicationTransactionId	Originator application transaction id	String	BHT03
transactionCreationDateTime	Transaction creation date time	Date and Time	BHT04, BHT05
claimOrEncounterIdentifierType	Claim or encounter identifier type	String	BHT06
patientControlNumber	Patient control number	String	CLM01
chargeAmount	Charge amount	Number	CLM02
facility	Place of service code for professional/dental claims or UB facility code for institutional claims View codes and descriptions	Code	CLM05-1
frequencyTypeCode	Frequency type code View codes and descriptions	String	CLM05-3
assignmentParticipationCode	Assignment participation code	String	CLM07
assignmentCertificationIndicator	Assignment certification indicator	String	CLM08
releaseOfInformationCode	Release of information code	String	CLM09
delayReasonCode	Delay reason code	String	CLM20
billingProvider	Billing provider	Provider	NM1 *85
subscriber	The insured (subscriber)	Subscriber	NM1 *44
patient	Patient if different from the the insured (subscriber)	Patient	NM1 *QC
statementDateFrom	Statement date from	Date	DTP03 *434
statementDateTo	Statement date to	Date	DTP03 *434
dischargeTime	Discharge time	Time	DTP03 *096
admissionDateAndHour	Admission date and hour	Date and Time	DTP03 *435
admissionTypeCode	Admission type code	String	CL101
admissionSourceCode	Admission source code	String	CL102
patientStatusCode	Patient status code	String Required	CL103
patientResponsibilityAmount	Patient responsibility amount	Number	AMT02 *F3
serviceAuthorizationExceptionCode	Service authorization exception code	String	REF02 *4N
referralNumber	Referral number	String	REF02 *9F
priorAuthorizationNumber	Prior authorization number	String	REF02 *G1
payerClaimControlNumber	Payer claim control number	String	REF02 *F8
clearinghouseTraceNumber	Clearinghouse trace number	String	REF02 *D9
repricedReferenceNumber	Repriced reference number	String	REF02 *9A
adjustedRepricedReferenceNumber	Adjusted repriced reference number	String	REF02 *9C
accidentState	Accident state	String	REF02 *LU
medicalRecordNumber	Medical record number	String	REF02 *EA
demonstrationProjectIdentifier	Demonstration project identifier	String	REF02 *P4
note	Free-form comments or instructions. All note segments are concatenated together into this field.	String	NTE02
billingNote	Billing note	String	NTE02 *ADD
principalDiag	Principal diagnosis	InstDiagnosis	HI *ABK
admittingDiag	Admitting diagnosis View codes and descriptions	Code	HI *ABJ
reasonForVisitDiags	Reason for visit diags View codes and descriptions	List of Code	HI *APR
externalCauseOfInjuryDiags	External cause of injury diags View codes and descriptions	List of Code	HI *ABN
drg	Drg	Code
otherDiags	Other diags	List of InstDiagnosis	HI *ABF
principalProcedure	Principal procedure View codes and descriptions	CodeAndDate	HI BBR, HI CAH
otherProcedures	Other procedures View codes and descriptions	List of CodeAndDate	HI *BBQ
occurrences	Occurrences View codes and descriptions	List of CodeAndDate	HI *BH
occurrenceSpans	Occurrence spans View codes and descriptions	List of CodeAndDate	HI *BI
conditions	Conditions View codes and descriptions	List of Code	HI *BG
valueInfos	Value infos View codes and descriptions	List of CodeAndAmount	HI *BE
attachments	Attachments	List of Attachment	PWK
attendingProvider	Attending provider	Party	NM1 *71
operatingPhysician	Operating physician	Provider	NM1 *72
otherOperatingPhysician	Other operating physician	Party	NM1 *ZZ
referringProvider	Referring provider	Party	NM1 *DN
renderingProvider	Rendering provider	Provider	NM1 *82
serviceFacility	Service facility	Party	NM1 *77
otherSubscribers	Other subscribers and their payer's information	List of OtherSubscriber	Loop: 2320
lines	Service lines	List of InstLineCsv	Loop: 2400

Service Line

Loop: 2400 Open API Schema

Name	Description	Type	EDI Element
controlNumber	Control number	String	REF02 *6R
revenueCode	Revenue code View codes and descriptions	Code Required	SV201
procedure	Procedure View codes and descriptions	Procedure	SV202 HC, SV202 AD, SV202 WK, SV202 IV
chargeAmount	Charge amount	Number Required	SV203
unitType	Unit type	String Required	SV204
unitCount	Unit count	Number Required	SV205
nonCoveredAmount	Non covered amount	Number	SV207
serviceDateFrom	Service period start date	Date	DTP03 472, DTP03 150
serviceDateTo	Service period end date. If not provided in EDI (single day), it is set to 'serviceDateFrom'	Date	DTP03 *151
repricedReferenceNumber	Repriced reference number	String	REF02 *9B
adjustedRepricedReferenceNumber	Adjusted repriced reference number	String	REF02 *9D
serviceTaxAmount	Service tax amount	Number	AMT02 *GT
facilityTaxAmount	Facility tax amount	Number	AMT02 *N8
thirdPartyNote	Third party note	String	NTE02
drug	Drug View codes and descriptions	Code	LIN03
drugQuantity	Drug quantity	Number	CTP04
drugUnitType	Drug unit type	String	CTP05-1
prescriptionNumber	Prescription number	String	REF02 *XZ
attachments	Attachments	List of Attachment	PWK
operatingPhysician	Operating physician	Provider	NM1 *72
otherOperatingPhysician	Other operating physician	Party	NM1 *ZZ
renderingProvider	Rendering provider	Provider	NM1 *82
referringProvider	Referring provider	Party	NM1 *DN

Subscriber

Open API Schema

Name	Description	Type	EDI Element
payerResponsibilitySequence	Payer responsibility sequence	String Required	SBR01
relationshipType	Relationship type	String	SBR02, PAT01
groupOrPolicyNumber	Group or policy number	String	SBR03
groupName	Group name	String	SBR04
claimFilingIndicatorCode	Claim filing indicator code	String	SBR09
insurancePlanType	Insurance plan type	String	SBR09
person	Person	PersonWithDemographic	NM1
deathDate	Death date	Date	PAT06
weight	Patient weight in pounds	Number	PAT08
pregnancyIndicator	Pregnancy indicator	String	PAT09
propertyCasualtyClaimNumber	Property casualty claim number	String	REF02 *Y4
payer	Payer	Party	NM1 *PR Loop: 2330B

Patient

Open API Schema

Name	Description	Type	EDI Element
relationshipType	Relationship type	String	SBR02, PAT01
person	Person	PersonWithDemographic	NM1
deathDate	Death date	Date	PAT06
weight	Patient weight in pounds	Number	PAT08
pregnancyIndicator	Pregnancy indicator	String	PAT09

Other Subscriber

Open API Schema

Name	Description	Type	EDI Element
payerResponsibilitySequence	Payer responsibility sequence	String Required	SBR01
relationshipType	Relationship type	String	SBR02, PAT01
groupOrPolicyNumber	Group or policy number	String	SBR03
groupName	Group name	String	SBR04
claimFilingIndicatorCode	Claim filing indicator code	String	SBR09
insurancePlanType	Insurance plan type	String	SBR09
person	Person	PersonWithDemographic	NM1
adjustments	Claim-level adjustments from this payer	List of Adjustment	CAS
payerPaidAmount	Payer paid amount	Number	AMT02 *D
nonCoveredAmount	Non covered amount	Number	AMT02 *A8
remainingPatientLiabilityAmount	Remaining patient liability amount	Number	AMT02 *EAF
outpatientAdjudication	Outpatient adjudication	OutpatientAdjudication	MOA
payerPriorAuthorizationNumber	Payer prior authorization number	String	REF02 *G1
payerReferralNumber	Payer referral number	String	REF02 *9F
payerClaimControlNumber	Payer claim control number	String	REF02 *F8
payer	Payer	Party	NM1 *PR Loop: 2330B
providers	Other payer's providers	List of Party	NM1

Organization Or Person ID and Name

Open API Schema

Name	Description	Type	EDI Element
entityRole	Entity role View codes and descriptions	String Required	NM101, N101
entityType	Type of this entity: 'BUSINESS' for organization, 'INDIVIDUAL' for person	String Required	NM102
identificationType	Identification type, e.g., NPI or EIN. This is a qualifier code translated to a string constant (enum)	String	NM108, N103
identifier	Identifier	String	NM109, N104
taxId	Tax id	String	REF02 TJ, REF02 SY, REF02 *EI
lastNameOrOrgName	Organization name or person last name	String	NM103, N102
firstName	First name	String	NM104
middleName	Middle name	String	NM105

Organization or Person (Party)

Open API Schema

Extends: PartyIdName

Name	Description	Type	EDI Element
address	Address	Address
contacts	Contacts	List of ContactInfo
additionalIds	Other identifications	List of Reference	REF

Provider

Open API Schema

Extends: Party

Name	Description	Type	EDI Element
providerTaxonomy	Provider's specialty information (taxonomy). Populated only for billing, rendering, operating providers. View codes and descriptions	Code	PRV

Person with Demographic Info

Open API Schema

Extends: Party

Name	Description	Type	EDI Element
birthDate	Birth date	Date	DMG02
gender	Gender	String	DMG03

Address

Open API Schema

Name	Description	Type	EDI Element
line	Line	String	N301
line2	Line2	String	N302
city	City	String	N401
stateCode	State code	String	N402
zipCode	Zip code	String	N403
countryCode	Country code	String	N404

Contact Info

Segment: PER Open API Schema

Name	Description	Type	EDI Element
functionCode	Function code	String Required	PER01
name	Name	String	PER02
contactNumbers	Contact numbers	List of ContactNumber

Contact Number

Segment: PER Open API Schema

Name	Description	Type	EDI Element
type	Type of contact number, such as PHONE, EMAIL, URL	String Required	PER03,PER05,PER07
number	Number	String Required	PER04,PER06,PER08

Diagnosis

Open API Schema

Extends: Code

Name	Description	Type	EDI Element
presentOnAdmissionIndicator	Present on admission indicator	String	HI01-9

Procedure

Procedure code with description and optional modifiers

Segment: HI,SV1,SV2,SV3,SVC Open API Schema

Extends: Code

Name	Description	Type	EDI Element
modifiers	Modifiers	List of Code	837P:SV101-3-6, 837I:SV201-3-6, 835:SVC01-3-6, 277:SVC01-3-6

Code with Date

The date is provided for procedures at a claim level and for occurrence codes.

Open API Schema

Extends: Code

Name	Description	Type	EDI Element
occurrenceDate	Occurrence date	Date Required	HI01-4

Code

Code and description

Open API Schema

Name	Description	Type
subType	Healthcare code subtype, such as CPT, HCPCS, ICD_10, NDC	String
code	Healthcare code	String Required
desc	Code description	String

Attachment

Segment: PWK Open API Schema

Name	Description	Type	EDI Element
reportTypeCode	Report type code	String Required	PWK01
reportTransmissionCode	Report transmission code	String Required	PWK02
controlNumber	Control number	String	PWK06

Reference Identifications

Segment: REF Open API Schema

Name	Description	Type	EDI Element
qualifierCode	Code qualifying the reference identification	String Required	REF01
type	Type of reference; qualifier code as a string constant (enum) View codes and descriptions	String	REF01
identification	Reference identification	String Required	REF02