837I Institutional Claim Schema
Claim
Name | Description | Type | EDI Element |
---|---|---|---|
id | Unique payment identifier assigned by the converter | String | |
objectType | Type of this object, set to 'CLAIM' | String | |
patientControlNumber | Identifier used to track a claim from creation by the health care provider through payment | String Required | CLM01 |
chargeAmount | Charge amount | Number Required | CLM02 |
facilityCode | Place of service code (professional/dental) or UB facility code (institutional) from the original claim View codes and descriptions | Code Required | CLM05-1 |
frequencyCode | Frequency code View codes and descriptions | Code Required | CLM05-3 |
statementDateFrom | Statement date from | Date | DTP03 *434 |
statementDateTo | Statement date to | Date | DTP03 *434 |
serviceDateFrom | The earliest service date from service lines | Date | |
serviceDateTo | The latest service date from service lines | Date | |
subscriber | The insured (subscriber) | Subscriber | Loop: 2000B |
patient | Patient if different from the the insured (subscriber) | Patient | Loop: 2110CA |
otherSubscribers | Other subscribers and their payer's information | List of OtherSubscriber | Loop: 2320 |
serviceLines | Service lines | List of InstLine | Loop: 2400 |
transaction | Parent EDI transaction for this object | Transaction837 | |
assignmentParticipationCode | Assignment participation code | String Required | CLM07 |
assignmentCertificationIndicator | Assignment certification indicator | String Required | CLM08 |
releaseOfInformationCode | Release of information code | String Required | CLM09 |
delayReasonCode | Delay reason code | String | CLM20 |
serviceAuthorizationExceptionCode | Service authorization exception code | String | REF02 *4N |
referralNumber | Referral number | String | REF02 *9F |
priorAuthorizationNumber | Prior authorization number | String | REF02 *G1 |
originalReferenceNumber | Original reference number | String | REF02 *F8 |
repricedReferenceNumber | Repriced reference number | String | REF02 *9A |
adjustedRepricedReferenceNumber | Adjusted repriced reference number | String | REF02 *9C |
clearinghouseTraceNumber | Clearinghouse trace number | String | REF02 *D9 |
accidentState | Accident state | String | REF02 *LU |
medicalRecordNumber | Medical record number | String | REF02 *EA |
peerReviewAuthorizationNumber | Peer review authorization number | String | REF02 *G4 |
demonstrationProjectIdentifier | Demonstration project identifier | String | REF02 *P4 |
admissionDateAndHour | Admission date and hour | Date and Time | DTP03 *435 |
dischargeTime | Discharge time | Time | DTP03 *096 |
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 |
fixedFormatRecords | Fixed format records | List of String | K301 |
claimNote | Free-form comments or instructions. All note segments are concatenated together into this field. | String | NTE02 |
billingNote | Billing note | String | NTE02 *ADD |
billingProvider | Billing provider | Provider | NM1 *85 |
providers | Providers for this claim, except for the billing provider | List of Provider | |
diags | Diagnosis codes | List of InstDiagnosis | HI |
drg | Drg | Code | HI *DR |
procs | Claim-level procedures View codes and descriptions | List of CodeAndDate | HI |
occurrenceSpans | Occurrence spans View codes and descriptions | List of CodeAndDate | HI *BI |
occurrences | Occurrences View codes and descriptions | List of CodeAndDate | HI *BH |
valueInfos | Value infos View codes and descriptions | List of CodeAndAmount | HI *BE |
conditions | Conditions View codes and descriptions | List of Code | HI *BG |
attachments | Attachments | List of Attachment | PWK |
Service Line
Loop: 2400, Segment: SV2 Open API Schema
Name | Description | Type | EDI Element |
---|---|---|---|
sourceLineId | Line item control number | String | REF02 *6R |
repricedReferenceNumber | Repriced reference number | String | REF02 *9B |
adjustedRepricedReferenceNumber | Adjusted repriced reference number | String | REF02 *9D |
chargeAmount | Charge amount | Number Required | SV203 |
nonCoveredAmount | Non covered amount | Number | SV207 |
serviceTaxAmount | Service tax amount | Number | AMT02 *GT |
facilityTaxAmount | Facility tax amount | Number | AMT02 *N8 |
serviceDateFrom | Service date from | Date | DTP03 *472 |
serviceDateTo | Service date to | Date | DTP03 *472 |
unitType | Unit type | String Required | SV204 |
unitCount | Unit count | Number Required | SV205 |
thirdPartyNote | Third party note | String | NTE02 *TPO |
procedure | Procedure View codes and descriptions | Procedure | SV202 *HC, SV202 *AD, SV202 *WK, SV202 *IV |
revenueCode | Revenue code View codes and descriptions | Code | SV201 *RC,NU |
attachments | Attachments | List of Attachment | PWK |
providers | Providers for this service line | List of Provider | |
adjudications | Adjudications | List of Adjudication | SVD Loop: 2430 |
adjustments | Copy of line adjustments from the adjudication list for backward compatibility | List of Adjustment | CAS |
fixedFormatRecords | Fixed format records | List of String | K301 |
Subscriber
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
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
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 |
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
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)
Extends: PartyIdName
Name | Description | Type | EDI Element |
---|---|---|---|
address | Address | Address | |
contacts | Contacts | List of ContactInfo | |
additionalIds | Other identifications | List of Reference | REF |
Provider
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
Extends: Party
Name | Description | Type | EDI Element |
---|---|---|---|
birthDate | Birth date | Date | DMG02 |
gender | Gender | String | DMG03 |
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 |
Adjudication
Loop: 2430, Segment: SVD Open API Schema
Name | Description | Type | EDI Element |
---|---|---|---|
payerIdentifier | Payer identifier | String | SVD01 |
paidAmount | Paid amount | Number | SVD02 |
unitCount | Unit count | Number | SVD05 |
bundledOrUnbundledLineNumber | Bundled or unbundled line number | Integer | SVD06 |
procedure | Procedure View codes and descriptions | Procedure | SVD03 |
adjustments | Line adjustments | List of Adjustment | CAS |
adjudicationOrPaymentDate | Adjudication or payment date | Date | DTP03 *573 |
remainingPatientLiabilityAmount | Remaining patient liability amount | Number | AMT02 *EAF |
Adjustment
Segment: CAS Open API Schema
Name | Description | Type | EDI Element |
---|---|---|---|
group | Claim adjustment group code as a string constant (enum) | String Required | CAS01 |
reasonCode | Claim adjustment reason code View codes and descriptions | String Required | CAS02 |
amount | Adjustment amount | Number Required | CAS03 |
quantity | Adjustment quantity | Number | CAS04 |
Diagnosis
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.
Extends: Code
Name | Description | Type | EDI Element |
---|---|---|---|
occurrenceDate | Occurrence date | Date | HI01-4 |
Code with Amount
The amount is provided for value codes
Extends: Code
Name | Description | Type | EDI Element |
---|---|---|---|
amount | Amount | Number | HI01-5 |
Code
Code and description
Name | Description | Type | EDI Element |
---|---|---|---|
subType | Healthcare code subtype, such as CPT, HCPCS, ICD_10, NDC | String | |
code | Healthcare code | String Required | |
desc | Code description | String |
EDI Transaction Info
Name | Description | Type | EDI Element |
---|---|---|---|
controlNumber | Control number | String | ST02 |
transactionType | Transaction type translated to string constant, PROF for 837P, INST for 837I, etc. | String | ST01, ST03 |
hierarchicalStructureCode | Hierarchical structure code | String | BHT01 |
purposeCode | Purpose code | String | BHT02 |
originatorApplicationTransactionId | Originator application transaction id | String | BHT03 |
creationDate | Creation date | Date | BHT04 |
creationTime | Creation time | Time | BHT05 |
claimOrEncounterIdentifierType | Claim or encounter identifier type | String | BHT06 |
transactionSetIdentifierCode | Transaction set identifier code | String | ST01 |
implementationConventionReference | Implementation convention reference | String | ST03 |
fileInfo | File info | FileInfo | |
sender | Submitter or sender of this transaction | PartyIdName | |
receiver | Receiver of this transaction | PartyIdName |
File Info
Name | Description | Type | EDI Element |
---|---|---|---|
name | File name | String | |
url | URL of the file, including the full path | String | |
lastModifiedDateTime | Last modified date and time of the file | Date and Time |