837P Professional Claim Schema

Overview

Resources:

Claim

Loop: 2300, Segment: CLM JSON Example Interactive Example Open API Schema

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
patientPaidAmount	Patient paid amount	Number	AMT02 *F5
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
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 ProfLine	Loop: 2400
transaction	Parent EDI transaction for this object	Transaction837
providerSignatureIndicator	Provider signature indicator	String Required	CLM06
assignmentParticipationCode	Assignment participation code	String Required	CLM07
assignmentCertificationIndicator	Assignment certification indicator	String Required	CLM08
releaseOfInformationCode	Release of information code	String Required	CLM09
specialProgramCode	Special program code	String	CLM12
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
medicalRecordNumber	Medical record number	String	REF02 *EA
demonstrationProjectIdentifier	Demonstration project identifier	String	REF02 *P4
onsetOfCurrentIllnessOrInjuryDate	Onset of current illness or injury date	Date	DTP03 *431
initialTreatmentDate	Initial treatment date	Date	DTP03 *454
lastSeenDate	Last seen date	Date	DTP03 *304
acuteManifestationDate	Acute manifestation date	Date	DTP03 *453
accidentDate	Accident date	Date	DTP03 *439
lastMenstrualPeriodDate	Last menstrual period date	Date	DTP03 *484
lastXRayDate	Last xray date	Date	DTP03 *455
prescriptionDate	Hearing and vision prescription date	Date	DTP03 *471
disabilityDateFrom	Disability date from	Date	DTP03 *314
disabilityDateTo	Disability date to	Date	DTP03 *361
lastWorkedDate	Last worked date	Date	DTP03 *297
authorizedReturnToWorkDate	Authorized return to work date	Date	DTP03 *296
admissionDate	Admission date for ambulance claims	Date	DTP03 *435
dischargeDate	Discharge date	Date	DTP03 *096
assumedCareDate	Assumed care date	Date	DTP03 *090
relinquishedCareDate	Relinquished care date	Date	DTP03 *091
propertyCasualtyFirstContactDate	Property casualty first contact date	Date	DTP03 *444
repricerReceivedDate	Repricer received date	Date	DTP03 *050
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
billingProvider	Billing provider	Provider	NM1 *85
providers	Providers for this claim, except for the billing provider	List of Provider
diags	Diagnosis codes View codes and descriptions	List of Code Required	HI
procs	Anesthesia-related procedures View codes and descriptions	List of Code	HI
conditions	Conditions View codes and descriptions	List of Code	HI *BG
attachments	Attachments	List of Attachment	PWK

Service Line

Loop: 2400, Segment: SV1 Open API Schema

Name	Description	Type	EDI Element
sourceLineId	Line item control number	String	REF02 *6R
placeOfServiceCode	Place of service code	String	SV105
emergencyIndicator	Emergency indicator	String	SV109
epsdtIndicator	Epsdt indicator	String	SV111
familyPlanningIndicator	Family planning indicator	String	SV112
copayStatusCode	Copay status code	String	SV115
repricedReferenceNumber	Repriced reference number	String	REF02 *9B
adjustedRepricedReferenceNumber	Adjusted repriced reference number	String	REF02 *9D
priorAuthorization	Prior authorization	String	REF02 *G1
referralNumber	Referral number	String	REF02 *9F
chargeAmount	Charge amount	Number Required	SV102
salesTaxAmount	Sales tax amount	Number	AMT02 *T
serviceDateFrom	Service date from	Date	DTP03 *472
serviceDateTo	Service date to	Date	DTP03 *472
prescriptionDate	Prescription date	Date	DTP03 *471
beginTherapyDate	Begin therapy date	Date	DTP03 *463
lastSeenDate	Last seen date	Date	DTP03 *304
testPerformedDate	Test performed date	Date	DTP03 738, DTP03 739
lastXRayDate	Last xray date	Date	DTP03 *455
initialTreatmentDate	Initial treatment date	Date	DTP03 *454
unitType	Unit type	String Required	SV103
unitCount	Unit count	Number Required	SV104
drug	Drug code (NDC) View codes and descriptions	Code	LIN03
drugQuantity	Drug quantity	Number	CTP04
drugUnitType	Drug unit type	String	CTP05-1
prescriptionNumber	Prescription number	String	REF02 *XZ
lineNote	Line note	String	NTE02 ADD, NTE02 DCP
thirdPartyNote	Third party note	String	NTE02 *TPO
procedure	Procedure View codes and descriptions	Procedure	SV101 HC, SV101 AD, SV101 WK, SV101 IV
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
diagPointers	Diagnosis pointers. Each pointer is an index of the diagnosis in the 'diags' array at the claim level.	List of Integer Required	SV107
diags	Copy of diagnosis codes from the claim based on diagnosis pointers View codes and descriptions	List of Code	SV107

Subscriber

Open API Schema

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

Open API Schema

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

Open API Schema

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
outpatientAdjudication	Outpatient adjudication	OutpatientAdjudication	MOA
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

Outpatient Adjudication

Contains Remittance Advice Remark Codes at the claim level and/or Medicare or Medicaid-specific amounts for outpatient claims

Segment: MOA Open API Schema

Name	Description	Type	EDI Element
reimbursementRate	Reimbursement rate	Number	MOA01
hcpcsPayableAmount	Claim HCPCS Payable Amount	Number	MOA02
esrdPaymentAmount	Esrd payment amount	Number	MOA08
nonPayableProfessionalComponentAmount	Nonpayable Professional Component Amount	Number	MOA09
remarks	Remark codes View codes and descriptions	List of Code	MOA3:7

Organization Or Person ID and Name

Open API Schema

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)

Open API Schema

Extends: PartyIdName

Name	Description	Type	EDI Element
address	Address	Address
contacts	Contacts	List of ContactInfo
additionalIds	Other identifications	List of Reference	REF

Provider

Open API Schema

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

Open API Schema

Extends: Party

Name	Description	Type	EDI Element
birthDate	Birth date	Date	DMG02
gender	Gender	String	DMG03

Address

Open API Schema

Name	Description	Type	EDI Element
line	Line	String	N301
line2	Line2	String	N302
city	City	String	N401
stateCode	State code	String	N402
zipCode	Zip code	String	N403
countryCode	Country code	String	N404

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
reason	Claim adjustment reason code View codes and descriptions	Code Required	CAS02
amount	Adjustment amount	Number Required	CAS03
quantity	Adjustment quantity	Number	CAS04

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

Code and description

Open API Schema

Name	Description	Type
subType	Healthcare code subtype, such as CPT, HCPCS, ICD_10, NDC	String
code	Healthcare code	String Required
desc	Code description	String

EDI Transaction Info

Open API Schema

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

Open API Schema

Name	Description	Type
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