JSON Schema for 837I (Institutional Claim)

Unique payment identifier assigned by the converter

Type of this object, set to 'CLAIM'

Identifier used to track a claim from creation by the health care provider through payment

Charge amount

Place of service code (professional/dental) or UB facility code (institutional) from the original claim

View codes and descriptions

Frequency code

View codes and descriptions

Statement date from

Statement date to

The earliest service date from service lines

The latest service date from service lines

The insured (subscriber)

Patient if different from the the insured (subscriber)

Other subscribers and their payer's information

Service lines

Parent EDI transaction for this object

Assignment participation code

Assignment certification indicator

Release of information code

Delay reason code

Service authorization exception code

Referral number

Prior authorization number

Original reference number

Repriced reference number

Adjusted repriced reference number

Clearinghouse trace number

Accident state

Medical record number

Peer review authorization number

Demonstration project identifier

Admission date and hour

Discharge time

Admission type code

Admission source code

Patient status code

Patient responsibility amount

Fixed format records

Free-form comments or instructions. All note segments are concatenated together into this field

Billing note

Billing provider

Pay to address

Pay-to plan for subrogation claims

Providers for this claim, except for the billing provider

Diagnosis codes

Drg

Claim-level procedures

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Occurrence spans

View codes and descriptions

Occurrences

View codes and descriptions

Value infos

View codes and descriptions

Conditions

View codes and descriptions

Attachments

Contract info

Conditions indicators

Line item control number

Repriced reference number

Adjusted repriced reference number

Charge amount

Non covered amount

Service tax amount

Facility tax amount

Service date from

Service date to

Unit type

Unit count

Third party note

Procedure

View codes and descriptions

Revenue code

View codes and descriptions

Attachments

Contract info

Providers for this service line

Adjudications

Copy of line adjustments from the adjudication list for backward compatibility

Fixed format records

Payer responsibility sequence

Values:

EIGHT(E), ELEVEN(H), FIVE(B), FOUR(A), NINE(F), PRIMARY(P), SECONDARY(S), SEVEN(D), SIX(C), TEN(G), TERTIARY(T), UNCONFIRMED(N), UNKNOWN(U)

Relationship type

Values:

CADAVER_DONOR(40), CHILD(19), EMPLOYEE(20), LIFE_PARTNER(53), ORGAN_DONOR(39), OTHER(G8), SELF(18), SPOUSE(1), UNKNOWN(21)

Group or policy number

Group name

Claim filing indicator code

Insurance plan type

Values:

AUTOMOBILE_MEDICAL(AM), BCBS(BL), CHAMPUS(CH), COMMERCIAL(CI), EPO(14), FEDERAL_EMPLOYEE_PROGRAM(FI), HMO(HM), HMO_MEDICARE(16), INDEMNITY_INSURANCE(15), MEDICAID(MC), MEDICARE_A(MA), MEDICARE_B(MB), MUTUALLY_DEFINED(ZZ), OTHER_FEDERAL(OF), OTHER_NON_FEDERAL(11), POS(13), PPO(12), VETERAN_AFFAIRS(VA), WORKERS_COMPENSATION(WC)

Person

Death date

Patient weight in pounds

Pregnancy indicator

Property casualty claim number

Payer

Relationship type

Values:

CADAVER_DONOR(40), CHILD(19), EMPLOYEE(20), LIFE_PARTNER(53), ORGAN_DONOR(39), OTHER(G8), SELF(18), SPOUSE(1), UNKNOWN(21)

Person

Death date

Patient weight in pounds

Pregnancy indicator

Payer responsibility sequence

Values:

EIGHT(E), ELEVEN(H), FIVE(B), FOUR(A), NINE(F), PRIMARY(P), SECONDARY(S), SEVEN(D), SIX(C), TEN(G), TERTIARY(T), UNCONFIRMED(N), UNKNOWN(U)

Relationship type

Values:

CADAVER_DONOR(40), CHILD(19), EMPLOYEE(20), LIFE_PARTNER(53), ORGAN_DONOR(39), OTHER(G8), SELF(18), SPOUSE(1), UNKNOWN(21)

Group or policy number

Group name

Coordination of benefits code, post-adjudicated claims only

Claim filing indicator code

Insurance plan type

Values:

AUTOMOBILE_MEDICAL(AM), BCBS(BL), CHAMPUS(CH), COMMERCIAL(CI), EPO(14), FEDERAL_EMPLOYEE_PROGRAM(FI), HMO(HM), HMO_MEDICARE(16), INDEMNITY_INSURANCE(15), MEDICAID(MC), MEDICARE_A(MA), MEDICARE_B(MB), MUTUALLY_DEFINED(ZZ), OTHER_FEDERAL(OF), OTHER_NON_FEDERAL(11), POS(13), PPO(12), VETERAN_AFFAIRS(VA), WORKERS_COMPENSATION(WC)

Person

Claim-level adjustments from this payer

Payer paid amount

Non covered amount

Remaining patient liability amount

Outpatient adjudication

Payer prior authorization number

Payer referral number

Payer claim control number

Payer

Patient's information; post-adjudicated claims only

Other payer's providers

Reimbursement rate

Claim HCPCS Payable Amount

Esrd payment amount

Nonpayable Professional Component Amount

Remark codes

View codes and descriptions

Covered days or visits count

Pps operating outlier amount

Lifetime psychiatric days count

Drg amount

Disproportionate share amount

Msp pass through amount

Pps capital amount

Pps capital fsp drg amount

Pps capital hsp drg amount

Pps capital dsh drg amount

Old capital amount

Pps capital ime amount

Pps operating hospital specific drg amount

Cost report day count

Pps operating federal specific drg amount

Pps capital outlier amount

Indirect teaching amount

Non payable professional component amount

Pps capital exception amount

Remark codes

View codes and descriptions

Entity role

View codes and descriptions

Type of this entity: 'BUSINESS' for organization, 'INDIVIDUAL' for person

Values:

BUSINESS(2), INDIVIDUAL(1)

Identification type, e.g., NPI or EIN. This is a qualifier code translated to a string constant (enum)

View codes and descriptions

Identifier

Tax id

Organization name or person last name

First name

Middle name

Address

Contacts

Other identifications

Provider's specialty information (taxonomy). Populated only for billing, rendering, operating providers.

View codes and descriptions

Birth date

Gender

Values:

FEMALE(F), MALE(M), UNKNOWN(U)

Function code

Name

Contact numbers

Type of contact number

Values:

ALTERNATE_PHONE, BEEPER, CELL_PHONE, EMAIL, EXTENSION, FAX, HOME_PHONE, PHONE, UNKNOWN, URL, WORK_PHONE

Number

Payer identifier

Paid amount

Unit count

Bundled or unbundled line number

Procedure

View codes and descriptions

Line adjustments

Adjudication or payment date

Remaining patient liability amount

Claim adjustment group code as a string constant

Values:

CONTRACTUAL(CO), CORRECTION(CR), OTHER(OA), PATIENT_RESPONSIBILITY(PR), PAYOR_INITIATED(PI)

Claim adjustment reason code

View codes and descriptions

Adjustment amount

Adjustment quantity

Report type code

Report transmission code

Control number

Contract type code

Amount

Percentage

Contract code

Term discount percentage

Version identifier

Category code

Category code as constant (enum)

Values:

AMBULANCE_CERTIFICATION(07), DME_CERTIFICATION(09), EPSDT_MUTUALLY_DEFINED(ZZ), FUNCTIONAL_LIMITATIONS(75), HOSPICE(75), VISION_CONTACT_LENSES(E2), VISION_SPECTACLE_FRAMES(E3), VISION_SPECTACLE_LENSES(E1)

Yes or no condition

Values:

Y, N

Condition codes

Present on admission indicator

Modifiers

Occurrence date

Amount

Healthcare code subtype, such as CPT, HCPCS, ICD_10, NDC

Healthcare code

Code description

Control number

Transaction type translated to string constant, PROF for 837P, INST for 837I, etc.

Hierarchical structure code

Purpose code

Originator application transaction id

Creation date

Creation time

Claim or encounter identifier type

Transaction set identifier code

Implementation convention reference

File info

Submitter or sender of this transaction

Receiver of this transaction

File name

URL of the file, including the full path

Last modified date and time of the file