837I Institutional Claim Schema

Claim

NameDescriptionTypeEDI Element
idUnique payment identifier assigned by the converterString
objectTypeType of this object, set to 'CLAIM'String
patientControlNumberIdentifier used to track a claim from creation by the health care provider through paymentString
Required
CLM01
chargeAmountCharge amountNumber
Required
CLM02
facilityCodePlace of service code (professional/dental) or UB facility code (institutional) from the original claim
View codes and descriptions
Code
Required
CLM05-1
frequencyCodeFrequency code
View codes and descriptions
Code
Required
CLM05-3
statementDateFromStatement date fromDateDTP03 *434
statementDateToStatement date toDateDTP03 *434
serviceDateFromThe earliest service date from service linesDate
serviceDateToThe latest service date from service linesDate
subscriberThe insured (subscriber)SubscriberLoop: 2000B
patientPatient if different from the the insured (subscriber)PatientLoop: 2110CA
otherSubscribersOther subscribers and their payer's informationList of OtherSubscriberLoop: 2320
serviceLinesService linesList of InstLineLoop: 2400
transactionParent EDI transaction for this objectTransaction837
assignmentParticipationCodeAssignment participation codeString
Required
CLM07
assignmentCertificationIndicatorAssignment certification indicatorString
Required
CLM08
releaseOfInformationCodeRelease of information codeString
Required
CLM09
delayReasonCodeDelay reason codeStringCLM20
serviceAuthorizationExceptionCodeService authorization exception codeStringREF02 *4N
referralNumberReferral numberStringREF02 *9F
priorAuthorizationNumberPrior authorization numberStringREF02 *G1
originalReferenceNumberOriginal reference numberStringREF02 *F8
repricedReferenceNumberRepriced reference numberStringREF02 *9A
adjustedRepricedReferenceNumberAdjusted repriced reference numberStringREF02 *9C
clearinghouseTraceNumberClearinghouse trace numberStringREF02 *D9
accidentStateAccident stateStringREF02 *LU
medicalRecordNumberMedical record numberStringREF02 *EA
peerReviewAuthorizationNumberPeer review authorization numberStringREF02 *G4
demonstrationProjectIdentifierDemonstration project identifierStringREF02 *P4
admissionDateAndHourAdmission date and hourDate and TimeDTP03 *435
dischargeTimeDischarge timeTimeDTP03 *096
admissionTypeCodeAdmission type codeStringCL101
admissionSourceCodeAdmission source codeStringCL102
patientStatusCodePatient status codeString
Required
CL103
patientResponsibilityAmountPatient responsibility amountNumberAMT02 *F3
fixedFormatRecordsFixed format recordsList of StringK301
claimNoteFree-form comments or instructions. All note segments are concatenated together into this field.StringNTE02
billingNoteBilling noteStringNTE02 *ADD
billingProviderBilling providerProviderNM1 *85
providersProviders for this claim, except for the billing providerList of Provider
diagsDiagnosis codesList of InstDiagnosisHI
drgDrgCodeHI *DR
procsClaim-level procedures
View codes and descriptions
List of CodeAndDateHI
occurrenceSpansOccurrence spans
View codes and descriptions
List of CodeAndDateHI *BI
occurrencesOccurrences
View codes and descriptions
List of CodeAndDateHI *BH
valueInfosValue infos
View codes and descriptions
List of CodeAndAmountHI *BE
conditionsConditions
View codes and descriptions
List of CodeHI *BG
attachmentsAttachmentsList of AttachmentPWK

Service Line

Loop: 2400, Segment: SV2 Open API Schema
NameDescriptionTypeEDI Element
sourceLineIdLine item control numberStringREF02 *6R
repricedReferenceNumberRepriced reference numberStringREF02 *9B
adjustedRepricedReferenceNumberAdjusted repriced reference numberStringREF02 *9D
chargeAmountCharge amountNumber
Required
SV203
nonCoveredAmountNon covered amountNumberSV207
serviceTaxAmountService tax amountNumberAMT02 *GT
facilityTaxAmountFacility tax amountNumberAMT02 *N8
serviceDateFromService date fromDateDTP03 *472
serviceDateToService date toDateDTP03 *472
unitTypeUnit typeString
Required
SV204
unitCountUnit countNumber
Required
SV205
thirdPartyNoteThird party noteStringNTE02 *TPO
procedureProcedure
View codes and descriptions
ProcedureSV202 *HC, SV202 *AD, SV202 *WK, SV202 *IV
revenueCodeRevenue code
View codes and descriptions
CodeSV201 *RC,NU
attachmentsAttachmentsList of AttachmentPWK
providersProviders for this service lineList of Provider
adjudicationsAdjudicationsList of AdjudicationSVD
Loop: 2430
adjustmentsCopy of line adjustments from the adjudication list for backward compatibilityList of AdjustmentCAS
fixedFormatRecordsFixed format recordsList of StringK301

Subscriber

NameDescriptionTypeEDI Element
payerResponsibilitySequencePayer responsibility sequenceString
Required
SBR01
relationshipTypeRelationship typeStringSBR02, PAT01
groupOrPolicyNumberGroup or policy numberStringSBR03
groupNameGroup nameStringSBR04
claimFilingIndicatorCodeClaim filing indicator codeStringSBR09
insurancePlanTypeInsurance plan typeStringSBR09
personPersonPersonWithDemographicNM1
deathDateDeath dateDatePAT06
weightPatient weight in poundsNumberPAT08
pregnancyIndicatorPregnancy indicatorStringPAT09
propertyCasualtyClaimNumberProperty casualty claim numberStringREF02 *Y4
payerPayerPartyNM1 *PR
Loop: 2330B

Patient

NameDescriptionTypeEDI Element
relationshipTypeRelationship typeStringSBR02, PAT01
personPersonPersonWithDemographicNM1
deathDateDeath dateDatePAT06
weightPatient weight in poundsNumberPAT08
pregnancyIndicatorPregnancy indicatorStringPAT09

Other Subscriber

NameDescriptionTypeEDI Element
payerResponsibilitySequencePayer responsibility sequenceString
Required
SBR01
relationshipTypeRelationship typeStringSBR02, PAT01
groupOrPolicyNumberGroup or policy numberStringSBR03
groupNameGroup nameStringSBR04
claimFilingIndicatorCodeClaim filing indicator codeStringSBR09
insurancePlanTypeInsurance plan typeStringSBR09
personPersonPersonWithDemographicNM1
adjustmentsClaim-level adjustments from this payerList of AdjustmentCAS
payerPaidAmountPayer paid amountNumberAMT02 *D
nonCoveredAmountNon covered amountNumberAMT02 *A8
remainingPatientLiabilityAmountRemaining patient liability amountNumberAMT02 *EAF
payerPriorAuthorizationNumberPayer prior authorization numberStringREF02 *G1
payerReferralNumberPayer referral numberStringREF02 *9F
payerClaimControlNumberPayer claim control numberStringREF02 *F8
payerPayerPartyNM1 *PR
Loop: 2330B
providersOther payer's providersList of PartyNM1

Organization Or Person ID and Name

NameDescriptionTypeEDI Element
entityRoleEntity role
View codes and descriptions
String
Required
NM101, N101
entityTypeType of this entity: 'BUSINESS' for organization, 'INDIVIDUAL' for personString
Required
NM102
identificationTypeIdentification type, e.g., NPI or EIN. This is a qualifier code translated to a string constant (enum)StringNM108, N103
identifierIdentifierStringNM109, N104
taxIdTax idStringREF02 *TJ, REF02 *SY, REF02 *EI
lastNameOrOrgNameOrganization name or person last nameStringNM103, N102
firstNameFirst nameStringNM104
middleNameMiddle nameStringNM105

Organization or Person (Party)

Extends: PartyIdName
NameDescriptionTypeEDI Element
addressAddressAddress
contactsContactsList of ContactInfo
additionalIdsOther identificationsList of ReferenceREF

Provider

Extends: Party
NameDescriptionTypeEDI Element
providerTaxonomyProvider's specialty information (taxonomy). Populated only for billing, rendering, operating providers.
View codes and descriptions
CodePRV

Person with Demographic Info

Extends: Party
NameDescriptionTypeEDI Element
birthDateBirth dateDateDMG02
genderGenderStringDMG03

Contact Info

Segment: PER Open API Schema
NameDescriptionTypeEDI Element
functionCodeFunction codeString
Required
PER01
nameNameStringPER02
contactNumbersContact numbersList of ContactNumber

Contact Number

Segment: PER Open API Schema
NameDescriptionTypeEDI Element
typeType of contact number, such as PHONE, EMAIL, URLString
Required
PER03,PER05,PER07
numberNumberString
Required
PER04,PER06,PER08

Adjudication

Loop: 2430, Segment: SVD Open API Schema
NameDescriptionTypeEDI Element
payerIdentifierPayer identifierStringSVD01
paidAmountPaid amountNumberSVD02
unitCountUnit countNumberSVD05
bundledOrUnbundledLineNumberBundled or unbundled line numberIntegerSVD06
procedureProcedure
View codes and descriptions
ProcedureSVD03
adjustmentsLine adjustmentsList of AdjustmentCAS
adjudicationOrPaymentDateAdjudication or payment dateDateDTP03 *573
remainingPatientLiabilityAmountRemaining patient liability amountNumberAMT02 *EAF

Adjustment

Segment: CAS Open API Schema
NameDescriptionTypeEDI Element
groupClaim adjustment group code as a string constant (enum)String
Required
CAS01
reasonCodeClaim adjustment reason code
View codes and descriptions
String
Required
CAS02
amountAdjustment amountNumber
Required
CAS03
quantityAdjustment quantityNumberCAS04

Diagnosis

Extends: Code
NameDescriptionTypeEDI Element
presentOnAdmissionIndicatorPresent on admission indicatorStringHI01-9

Procedure

Procedure code with description and optional modifiers
Segment: HI,SV1,SV2,SV3,SVC Open API Schema
Extends: Code
NameDescriptionTypeEDI Element
modifiersModifiersList of Code837P: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.

Extends: Code
NameDescriptionTypeEDI Element
occurrenceDateOccurrence dateDateHI01-4

Code with Amount

The amount is provided for value codes

Extends: Code
NameDescriptionTypeEDI Element
amountAmountNumberHI01-5

Code

Code and description
NameDescriptionTypeEDI Element
subTypeHealthcare code subtype, such as CPT, HCPCS, ICD_10, NDCString
codeHealthcare codeString
Required
descCode description String

EDI Transaction Info

NameDescriptionTypeEDI Element
controlNumberControl numberStringST02
transactionTypeTransaction type translated to string constant, PROF for 837P, INST for 837I, etc.StringST01, ST03
hierarchicalStructureCodeHierarchical structure codeStringBHT01
purposeCodePurpose codeStringBHT02
originatorApplicationTransactionIdOriginator application transaction idStringBHT03
creationDateCreation dateDateBHT04
creationTimeCreation timeTimeBHT05
claimOrEncounterIdentifierTypeClaim or encounter identifier typeStringBHT06
transactionSetIdentifierCodeTransaction set identifier codeStringST01
implementationConventionReferenceImplementation convention referenceStringST03
fileInfoFile infoFileInfo
senderSubmitter or sender of this transactionPartyIdName
receiverReceiver of this transactionPartyIdName

File Info

NameDescriptionTypeEDI Element
nameFile nameString
urlURL of the file, including the full pathString
lastModifiedDateTimeLast modified date and time of the fileDate and Time