837I Institutional Claim Schema

Claim

Loop: 2300, Segment: CLM JSON Example Interactive Example

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	CLM01
chargeAmount	Charge amount	Number	CLM02
facilityCode	Place of service code (professional/dental) or UB facility code (institutional) from the original claim View codes and descriptions	Code	CLM05-1
frequencyCode	Frequency code View codes and descriptions	Code	CLM05-3
statementDateFrom	Statement date from	Date	DTP03 434, DTP03 232
statementDateTo	Statement date to	Date	DTP03 434, DTP03 233
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 ServiceLine	Loop: 2400
transaction	Parent EDI transaction for this object	Transaction
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
referralNumber	Referral number	String	REF02 *9F
priorAuthorizationNumber	Prior authorization number	String	REF02 *G1
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
admissionDateAndHour	Admission date and hour	Date and Time	DTP03 *435
dischargeTime	Discharge time	Time	DTP03 *096
clearinghouseTraceNumber	Clearinghouse trace number	String	REF02 *D9
admissionTypeCode	Admission type code	String	CL101
admissionSourceCode	Admission source code	String	CL102
patientStatusCode	Patient status code	String	CL103
originalReferenceNumber	Original reference number	String	REF02 *F8
patientResponsibilityAmount	Patient responsibility amount	Number	AMT02 *F3
serviceAuthorizationExceptionCode	Service authorization exception code	String	REF02 *4N
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	Party	NM1 *85
providers	Providers for this claim, except for the billing provider	Party
diags	Diagnosis codes View codes and descriptions	List of Diagnosis
procs	Claim-level procedures View codes and descriptions	List of CodeAndDate
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 Code	HI *BE
attachments	Attachments	List of Attachment	PWK

Service Line

Loop: 2400, Segment: SV2

Name	Description	Type	EDI Element
sourceLineId	Source line id	String	REF02 *6R
copayStatusCode	Copay status code	String	SV115
repricedReferenceNumber	Repriced reference number	String	REF02 *9A
adjustedRepricedReferenceNumber	Adjusted repriced reference number	String	REF02 *9D
chargeAmount	Charge amount	Number	SV203
nonCoveredAmount	Non covered amount	Number	AMT02 *A8
serviceTaxAmount	Service tax amount	Number	AMT02 *GT
facilityTaxAmount	Facility tax amount	Number	AMT02 *N8
unitType	Unit type	String	SV204
unitCount	Unit count	Number	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	Party
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	K301

Subscriber

Name	Description	Type	EDI Element
payerResponsibilitySequence	Payer responsibility sequence	String	SBR01
relationshipType	Relationship type	String	SBR02
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	PAT09
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
person	Person	PersonWithDemographic	NM1
deathDate	Death date	Date	PAT06
weight	Patient weight in pounds	Number	PAT09
pregnancyIndicator	Pregnancy indicator	String	PAT09

Other Subscriber

Name	Description	Type	EDI Element
payerResponsibilitySequence	Payer responsibility sequence	String	SBR01
relationshipType	Relationship type	String	SBR02
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
pregnancyIndicator	Pregnancy indicator	String	PAT09
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

Person with Demographic Info

Name	Description	Type	EDI Element
entityRole	Entity role View codes and descriptions	String	NM102, N101
entityType	Entity type	String	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
lastNameOrOrgName	Organization name or person last name	String	NM103, N102
firstName	First name	String	NM104
middleName	Middle name	String	NM105
birthDate	Birth date	Date	DMG02
gender	Gender	String	DMG03
address	Address	Address
contacts	Contacts	List of Contact
additionalIds	Other identifications	List of Reference	REF

Organization or Person (Party)

Name	Description	Type	EDI Element
entityRole	Entity role View codes and descriptions	String	NM102, N101
entityType	Entity type	String	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
lastNameOrOrgName	Organization name or person last name	String	NM103, N102
firstName	First name	String	NM104
middleName	Middle name	String	NM105
address	Address	Address
providerTaxonomy	Provider's specialty information (taxonomy). Populated only for billing, rendering, operating providers. View codes and descriptions	Code	PRV
contacts	Contacts	List of Contact
additionalIds	Other identifications	List of Reference	REF

Contact

Segment: PER

Name	Description	Type	EDI Element
name	Name	String	PER02
contactNumbers	Contact numbers	List of ContactNumber

Contact Number

Segment: PER

Name	Description	Type	EDI Element
type	Type	String	PER03,PER05,PER07
number	Number	String	PER04,PER06,PER08

Adjudication

Loop: 2430, Segment: SVD

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

Name	Description	Type	EDI Element
group	Claim adjustment group code as a string constant (enum)	String	CAS01
reasonCode	Claim adjustment reason code View codes and descriptions	String	CAS02
amount	Adjustment amount	Number	CAS03
quantity	Adjustment quantity	Number	CAS04

Diagnosis

Name	Description	Type	EDI Element
code	Healthcare code	String
desc	Code description	String
presentOnAdmissionIndicator	Present on admission indicator	String	HI01-9

Procedure

Procedure code with description and optional modifiers

Segment: HI,SV1,SV2,SVC

Name	Description	Type	EDI Element
code	Healthcare code	String
desc	Code description	String
modifiers	Modifiers	List of Code	837P:SV101-3-6, 837I:SV201-3-6, 835:SVC01-3-6

Code with Date

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

Name	Description	Type	EDI Element
code	Healthcare code	String
desc	Code description	String
occurrenceDate	Occurrence date	Date	HI01-4

Code

Code and description

Name	Description	Type	EDI Element
code	Healthcare code	String
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
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
originalTransactionSetReferenceNumber	Original transaction set reference number	String	BGN06
actionCode	Action code	String	BGN08
transactionSetIdentifierCode	Transaction set identifier code	String	ST01
implementationConventionReference	Implementation convention reference	String	ST03