837P Professional 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
patientPaidAmountPatient paid amountNumberAMT02 *F5
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
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 ProfLineLoop: 2400
transactionParent EDI transaction for this objectTransaction837
providerSignatureIndicatorProvider signature indicatorString
Required
CLM06
assignmentParticipationCodeAssignment participation codeString
Required
CLM07
assignmentCertificationIndicatorAssignment certification indicatorString
Required
CLM08
releaseOfInformationCodeRelease of information codeString
Required
CLM09
specialProgramCodeSpecial program codeStringCLM12
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
medicalRecordNumberMedical record numberStringREF02 *EA
demonstrationProjectIdentifierDemonstration project identifierStringREF02 *P4
onsetOfCurrentIllnessOrInjuryDateOnset of current illness or injury dateDateDTP03 *431
initialTreatmentDateInitial treatment dateDateDTP03 *454
lastSeenDateLast seen dateDateDTP03 *304
acuteManifestationDateAcute manifestation dateDateDTP03 *453
accidentDateAccident dateDateDTP03 *439
lastMenstrualPeriodDateLast menstrual period dateDateDTP03 *484
lastXRayDateLast xray dateDateDTP03 *455
prescriptionDateHearing and vision prescription dateDateDTP03 *471
disabilityDateFromDisability date fromDateDTP03 *314
disabilityDateToDisability date toDateDTP03 *361
lastWorkedDateLast worked dateDateDTP03 *297
authorizedReturnToWorkDateAuthorized return to work dateDateDTP03 *296
admissionDateAdmission date for ambulance claimsDateDTP03 *435
dischargeDateDischarge dateDateDTP03 *096
assumedCareDateAssumed care dateDateDTP03 *090
relinquishedCareDateRelinquished care dateDateDTP03 *091
propertyCasualtyFirstContactDateProperty casualty first contact dateDateDTP03 *444
repricerReceivedDateRepricer received dateDateDTP03 *050
fixedFormatRecordsFixed format recordsList of StringK301
claimNoteFree-form comments or instructions. All note segments are concatenated together into this field.StringNTE02
billingProviderBilling providerProviderNM1 *85
providersProviders for this claim, except for the billing providerList of Provider
diagsDiagnosis codes
View codes and descriptions
List of CodeHI
procsAnesthesia-related procedures
View codes and descriptions
List of CodeHI
conditionsConditions
View codes and descriptions
List of CodeHI *BG
attachmentsAttachmentsList of AttachmentPWK

Service Line

Loop: 2400, Segment: SV1 Open API Schema
NameDescriptionTypeEDI Element
sourceLineIdLine item control numberStringREF02 *6R
placeOfServiceCodePlace of service codeStringSV105
emergencyIndicatorEmergency indicatorStringSV109
epsdtIndicatorEpsdt indicatorStringSV111
familyPlanningIndicatorFamily planning indicatorStringSV112
copayStatusCodeCopay status codeStringSV115
repricedReferenceNumberRepriced reference numberStringREF02 *9B
adjustedRepricedReferenceNumberAdjusted repriced reference numberStringREF02 *9D
priorAuthorizationPrior authorizationStringREF02 *G1
referralNumberReferral numberStringREF02 *9F
chargeAmountCharge amountNumber
Required
SV102
salesTaxAmountSales tax amountNumberAMT02 *T
serviceDateFromService date fromDateDTP03 *472
serviceDateToService date toDateDTP03 *472
prescriptionDatePrescription dateDateDTP03 *471
beginTherapyDateBegin therapy dateDateDTP03 *463
lastSeenDateLast seen dateDateDTP03 *304
testPerformedDateTest performed dateDateDTP03 *738, DTP03 *739
lastXRayDateLast xray dateDateDTP03 *455
initialTreatmentDateInitial treatment dateDateDTP03 *454
unitTypeUnit typeString
Required
SV103
unitCountUnit countNumber
Required
SV104
drugDrug code (NDC)
View codes and descriptions
CodeLIN03
drugQuantityDrug quantityNumberCTP04
drugUnitTypeDrug unit typeStringCTP05-1
prescriptionNumberPrescription numberStringREF02 *XZ
lineNoteLine noteStringNTE02 *ADD, NTE02 *DCP
thirdPartyNoteThird party noteStringNTE02 *TPO
procedureProcedure
View codes and descriptions
ProcedureSV101 *HC, SV101 *AD, SV101 *WK, SV101 *IV
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
diagPointersDiagnosis pointers. Each pointer is an index of the diagnosis in the 'diags' array at the claim level.List of Integer
Required
SV107
diagsCopy of diagnosis codes from the claim based on diagnosis pointers
View codes and descriptions
List of CodeSV107

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

Address

NameDescriptionTypeEDI Element
lineLineStringN301
line2Line2StringN302
cityCityStringN401
stateCodeState codeStringN402
zipCodeZip codeStringN403
countryCodeCountry codeStringN404

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

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

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