837 101 Tutorial
Background
The
ANSI ASC X12 837 is the claim / encounter format. It is important to note all X12 formats are
messaging standards developed for the sole purpose
of transmitting data between two entities referred
to as trading partners in the HIPAA legislation. The organization of each ANSI ASC X12 standard
is determined by well-defined business needs. Specific
uses of each standard are defined in implementation
guides. There
are currently five (5) implementation guides written
for the 837 claim / encounter standard.
Current
837 Implementation Guides
·
Institutional
Claim Guide (X096) - This guide is named in the
HIPAA legislation.
·
Dental Claim Guide (X097) - This
guide is named in the HIPAA legislation.
·
Professional Claim Guide (X098) -
This guide is named in the HIPAA legislation.
·
Workers Compensation Reporting Guide
(X067) In Development
·
Health Care Service Data Reporting
Guide (X156) In Development
Note: The number in parenthesis is the Implementation
Guide number assigned by Washington Publishing Company,
which has the contract to publish ANSI ASC X12 implementation
guides.
Highlights
of the 837 Organizational Structure
The
837 standard is organized as described below.
Each implementation guide uses this structure,
but there will be some differences based on the
business needs being met by each respective implementation.
It is important to note that all the implementations
are restricted to the structure defined in the 837
standard itself.
·
Housekeeping information about the
837 Transaction Set reported.
o
HEADER Loop
o
Repeats 1 time
·
The submitter of the information
is identified with necessary contact information.
o
Loop ID - 1000
o
Repeats 1 time
·
The receiver of the information is identified with
necessary contact information.
o
Loop ID - 1000
o
Repeats 1 time
·
The provider of health care services is identified.
o
Loop ID – 2000
o
Repeats more than 1 time to allow submissions with
information from multiple providers
o
Each provider is labeled to enable identifying the
relationship between patients receiving care from
that provider later in the structure.
·
For each provider of health care services the patients
receiving care are identified.
o
Loop ID – 2010
o
Repeats more than 1 time to allow submissions with
information from multiple patients
o
A relationship is established between the provider
of the services and the patient receiving services
from that provider
o
Note: Because
one of the main functions of the 837 is for payment
of health care claims, the format supports reporting
of the subscriber of health insurance when that
subscriber is NOT the patient.
·
For each patient a variety of supporting information
is reported including but not restricted to demographic,
identifying, claim related dates, diagnosis, and
physician data.
o
Loop ID – 2300
o
Repeats up to 100 times to allow for multiple stays
for this patient
·
For each patient the potential payers for that service
are identified.
o
Loop ID – 2320
o
Repeats up to 10 times to allow for the reporting
of multiple payers for that health care service.
·
For each patient the services provided along with
associated charges are identified.
o
Loop ID – 2400
o
Repeats more than 1 to allow for the reporting of
multiple health care services for each patient.
Important
ANSI ASC X12 Syntax Concepts
·
Data in ANSI ASC X12 standards is organized into
segments. Each
segment contains multiple data elements, which are
classified as simple or composite. Data elements may contain coded information
maintained by ANSI ASC X12 (Internal code lists)
or by outside organizations (External code lists)
as well as qualified information.
·
Multiple occurrences of information is supported
by the looping structure in the 837 claim / encounter
standard. Parent / Child relationships between loops
is also supported in the 837 standards by use of
Hierarchical Levels (HL segments).
·
Segments and data elements in each loop are defined
as either required or situational in each implementation
guide. A statement of the usage of each situational
data element is defined in the implementation guide.
Web
Site References
www.x12.org
ANSI ASC X12 Official Web site.
For purposes of traversing this Web site,
the work done on the 837 is done in the Insurance
Subcommittee (N) in the Health Care Task Group (TG2)
and in Work group 2 (WG2).
Also available at this Web site for members
of X12 is a web-based workbook of the complete X12
standards. (click on Standards Development National
Standards Current X12 Standards Development Workbook)
www.wpc-edi.com The Washington Publishing Company web site. This web site
publishes the ANSI ASC X12 Implementation Guides
as well as a policy and procedure handbook for development
of implementation guides.
www.disa.org
The Data Interchange Standards Association
Web site.
This group is the secretariat for the ANSI
ASC X12 meetings that occur three times a year during
the first weeks of February, June, and October.
www.wedi.org
The Workgroup for Electronic Data Interchange
web site. This web site has information related to HIPAA as well as the Strategic
National Implementation Process (SNIP), which was
established to provide guidance implementing the
HIPAA legislation. Of particular interest in the HIPAA information is a comprehensive
glossary of terms.
www.ansi.org
The American National Standards Institute
web site. This state contains general information
about the ANSI organization.
