Healthcare Claim Types and EDI Transactions (HIPAA Transactions)
Transaction specifies the format of X12 EDI payload via loops and segments. Related transactions are grouped in transaction sets.
Healthcare claim transactions fall under the moniker of “837”. As per X12.org:
This transaction set can be used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses.
Healthcare transactions are sometimes called “HIPAA” EDI transactions. This is because X12 EDI was mandated as the data exchange standard in the US as part of the HIPAA legislation. The HIPAA requirement is one of the reasons why X12 EDI is so widespread (and deeply entrenched) in healthcare.
The “837” transaction set is used for submitting claims data. But it goes beyond just data transmission. The 837 standard also defines common vocabulary around claims and, indirectly, internal data models of industry participants.
There are three types of healthcare claims and, consequently, three 837 transaction types, explained below.
There is also a fourth primary claim type which is used in the pharmacy space. Confusingly enough, the pharmacy claim format is defined by a completely different standard called NCPDP Telecommunication. The NCPDP format is conceptually similar to X12 EDI, but it uses completely different separators and data elements. We will focus on 837 (a.k.a medical claims) here and save the NCPDP discussion for another post.
There are a lot of commonalities among all three 837 transactions. They all contain data about providers, patients/subscribers, diagnoses, and services (typically, medical procedures). Sometimes they also include information about drugs and medical equipment used for treatment.
Professional (837P) Transaction
“Professional” EDI transactions are used by all providers that are not hospitals. That is, doctors, physicians, physical therapists, etc., will all use this transaction type to submit their claims.
Most of the medical claims volume is in 837P format, since most of the healthcare treatments occur in a “professional” (that is, non-hospital) setting, e.g., in a medical office. The “place of service” field of 837P specifies where the services were performed (Office, home, telehealth, nursing facility, etc.).
In addition to the standard data elements describing patients, providers and treatments, professional claims could contain various relevant dates (onset of illness), ambulance information, referral number and a few other supplemental fields.
Professional claims use procedure codes (a.k.a. CPT codes) to specify services. Each code is accompanied by the number of units and charges. Here is a typical 837P’s “claim line” containing the code and the amount:
837P is based on the CMS-1500 form. This form, mandated by CMS and maintained by The National Uniform Claim Committee (NUCC), was the standard for claim submission before the advent of X12 EDI. Most of 837P segments were derived from CMS-1500 fields.
Institutional (837I) Transaction
837I is used by hospitals. It contains data elements to encode information related to hospitalization and inpatient treatment (admission date, discharge time).
Institutional claims use several code sets that are specific to institutional claims, for example, “occurrence date code”. Occurrence codes define dates or date ranges of various “events” that can be used to provide additional information related to services. E.g. the code
11 stands for “ONSET OF SYMPTOMS/ILLNESS”.
Institutional claims use the “revenue code” code sets to encode charges. The revenue code identifies the department in which the service was given, the types of services provided, and the supplies used. For example, the code
800 defines “Inpatient Renal Dialysis”.
Inpatient claims could omit procedure codes. Revenue codes are used at the line level; each comes with its own charge. Procedure codes could be defined at the claim level. Professional claims do not have this flexibility, they always provide charges for specific procedure codes.
Here is a typical 837I’s “claim line” utilizing the revenue code along with the CPT code:
Institutional code sets are governed by National Uniform Billing Committee (NUBC).
837I can also be used also for outpatient treatment. The type of treatment is determined by the “facility code” field, which is part of a composite code called “Type of Bill”. Note that professional services (billed on professional claims) could also be provided for outpatient treatment at a hospital facility. The transaction type is solely determined by the billing provider. A hospital will use 837I and non-hospitals will use 837P.
UB92 paper form was used as the starting point to develop 837I.
Dental (837D) Transaction
837D closely resembles 837P. It provides additional data elements specific to dental treatment.
Each service line could have an “Oral Cavity Designation Code.” There is also a tooth information segment to point to the actual tooth.
837D uses the procedure code set by American Dental Association as opposed to CPT/HCPCS.
The Rest of HIPAA Transactions
HIPAA also covers transactions dealing with enrolment, eligibility and payments:
- Health Care Claim Payment/Advice (835)
- Health Care Eligibility/Benefit Inquiry (270)
- Benefit Enrollment and Maintenance Set (834)
- Health Care Eligibility/Benefit Response (271)
- Health Care Claim Status Request (276)
- Health Care Claim Status Notification (277)
- Health Care Service Review Information (278)
Use our EDI viewer to review and analyze your EDI data; all HIPAA transactions are fully supported.
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