837 Professional Claim Scenario
The included example shows a standard 837 Professional claim file. It includes data from the provider of Service indicating the member’s demographic information, diagnosis, services rendered and charges. This data will be used by the Insurance Company to determine what benefits should be rendered.Here are the attributes of the example:
- The submitter of the claim is AGILE BILLING SOLUTIONS
- The receiver of the claim is BCBS DISNEY
- The billing provider is JOHN WATSON
- The patient “Mickey Mouse” is the subscriber
- The payer is BCBS DISNEY
- Mickey Mouse had felt like he had Diarrhea (ICD-9 787.91) and went to visit the doctor and the doctor diagnosed him with the stomach flu (e.g. Gastroenteritis) ICD-9 Codes 787.91 (primary), 009.0 (primary), 009.1, 558
- Mickey’s initial office visit was on January 24th, 2012 – Where Mickey spent 15 minutes with Dr. Watson face-to-face and the diagnosis code for Diarrhea was established – Procedure Code 99213 (HCPCS) – cost $50
After the office Visit Mickey went to the lab for a Stool Culture lab test procedure Code 87046 – cost $15 The lab services were performed at the BEST LAB COMPANY
837 Deciphering Raw Data BHT – 2000A
Beginning of Hierarchical Transaction: BHT*0019*00*004545*20120124*135420*CH
BHT01 Hierarchical Structure Code : Information Source, Subscriber, Dependent
BHT02 Transaction Set Purpose Code : Original
BHT03 Reference Identification : 004545
BHT04 Date : 1/24/2012
BHT05 Time : 1:54:20 PM
BHT06 Transaction Type Code : Chargeable
LOOP 1000A Submitter Name
Submitter Information: NM1*41*2*AGILE BILLING SOLUTIONS*****46*1981
NM101 Entity Identifier Code : Submitter
NM102 Entity Type Qualifier : Non-Person Entity
NM103 Name Last or Organization Name : AGILE BILLING SOLUTIONS
NM108 Identification Code Qualifier : Electronic Transmitter Identification Number (ETIN)
NM109 Identification Code : 1981
Submitter Contact Information: PER*IC*ANN GILLIS*TE*8185601000
PER01 Contact Type: Information Contact “IC”
PER02 Contact Name: ANN GILLIS
PER03 Communication Qualifier: Telephone “TE”
PER04 Telephone Number: 8185601000
LOOP 1000B Receiver Name
Receiver Information: NM1*40*2*BCBS DISNEY*****46*47198
NM101 Entity Identifier Code : Receiver “40″
NM102 Entity Type Qualifier : Non-Person Entity “2″
NM103 Name Last or Organization Name : BCBS DISNEY
NM108 Identification Code Qualifier : Electronic Transmitter Identification Number (ETIN) “46″
NM109 Identification Code : 47198
LOOP 2000A BILLING PROVIDER
Billing Provider Hierarchical Level: HL*1**20*1
HL01 Hierarchical ID: 1
HL02 Parent Hierarchical ID: No Parent
HL03 Hierarchy Level Name: “20″ = Information Source
HL04 Number of Hierarchical Children: 1 more additional subordinate HL
Provider Specialty Information: PRV*BI*PXC*207Q00000X
PRV01 Type of Provider: Billing “BI”
PRV02 Code Qualifier: Health Care Provider Taxonomy Code “PXC”
PRV03 Provider Taxonomy Code: 207Q00000X
837 Deciphering Raw Data 201AA – 2000B
LOOP 2010AA BILLING PROVIDER NAME
Billing Provider Information: NM1*85*1*WATSON*JOHN*H***XX*1134125736
NM101 Entity Identifier Code : Billing Provider “85″
NM102 Entity Type Qualifier : Person “1″
NM103 Name Last or Organization Name : WATSON
NM104 First Name: WATSON
NM103 Middle Name or Initial: WATSON
NM108 Identification Code Qualifier : National Provider Identifier “XX”
NM109 NPI: 1134125736
Billing Provider Address :N3*221 Baker Street
N301 Street Address: 221 Baker Street
Billing Provider City, State, ZIP Code: N4*ANAHEIM*CA*92802
N401 City: ANAHEIM
N402 State: CA
N403 Zip: 92802
Billing Provider Tax Identification: REF*EI*123456789
REF01 Reference Qualifier: Employer’s Identification Number “EI”
REF02 EIN: 123456789
LOOP 2000B SUBSCRIBER HIERARCHICAL
Subscriber Hierarchical Level: HL*2*1*22*0
HL01 Hierarchical ID: 2
HL02 Parent Hierarchical ID: 1 (Information Source/Billing Provider)
HL03 Hierarchy Level Name: “22″ = Subscriber
HL04 Number of Hierarchical Children: 0 (Subscriber is the patient)
Subscriber Information: SBR*P*18*******CI
SBR01 Payer Responsibility Sequence Number Code: Primary “P”
SBR02 Individual Relationship Code: Self “18″
SBR09 Code identifying type of claim: Commercial Insurance Co. “CI”
LOOP 2010BA SUBSCRIBER NAME
Subscriber Information: NM1*IL*1*MOUSE*MICKEY****MI*60345914A
NM101 Entity Identifier Code : Subscriber “IL”
NM102 Entity Type Qualifier : Person “1″
NM103 Subscriber Last Name: Mouse
NM104 Subscriber First Name: Mickey
NM108 Identification Code Qualifier : Member Identification Number “MI”
NM109 Member Identification Number: 60345914A
Subscriber Address: N3*1565 DISNEYLAND DRIVE
N301 Street Address: 1565 DISNEYLAND DRIVE
Subscriber City, State, ZIP Code: N4*ANAHEIM*CA*92802
N401 City: ANAHEIM
N402 State: CA
N403 Zip: 92802
Subscriber Demographic Information: DMG*D8*19281118*M
DMG01 Date Time Period Format Qualifier: Date Expressed in Format CCYYMMDD “D8″
DMG02 Subscriber Birth Date: 19281118
DMG03 Subscriber Gender Code: ‘M’ for Male
Subscriber Secondary Identification: REF*SY*055090001
REF01 Reference Qualifier: Social Security Number “SY”
REF02 SSN: 055090001
837 Deciphering Raw Data 2010BB – 2400
LOOP ID – 2010BB PAYER NAME
Payer Name: NM1*PR*2*BCBS DISNEY*****PI*8584537845
NM101 Entity Identifier Code : Payer “PR”
NM102 Entity Type Qualifier : Non-Person Entity “2″
NM103 Name Last or Organization Name : BCBS DISNEY
NM108 Identification Code Qualifier : National Plan ID “PI”
NM109 Identification Code : 8584537845
LOOP 2300 CLAIM INFORMATION
Claim Information: CLM*ABC7001*65***11:B:1*Y*A*Y*Y
CLM01 Claim ID: ABC7001
CLM02 Claim Amount: 65
CLM05-1 Place of Service Code: ’11′ Office
CLM05-2 Facility Code Qualifier: ‘B’ Place of Service Codes for Professional or Dental Services
CLM05-3 Claim Frequency Code: ’1′ The only bill to be received for a course of treatment
CLM06 Provider or Supplier Signature On File Indicator: ‘Y’ Yes
CLM07 Plan Participation Code: ‘A’ Assigned – Provider accepts agreement with payer
CLM08 Benefit Indicator: ‘Y’ Subscriber authorized payer to remit payment directly to the provider
CLM09 Release of Information Indicator: ‘Y’ Provider has a
Statement Permitting Release of Medical Billing Data Related to a Claim
ICD9Diagnosis Codes: HI*BK:78791*BF:0091*BF:558*BF:0090
HI01-1 ‘BK’ for (DX1) Primary Diagnosis HI01-2: 78791
HI02-1 ‘BF’ for (DX2) Supporting Diagnosis HI02-2: 0091
HI03-1 ‘BF’ for (DX3) Supporting Diagnosis HI03-2: 558
HI04-1 ‘BF’ for (DX4) Supporting Diagnosis HI04-2: 0090
LOOP 2400 SERVICE LINE
Service Line Number 1: LX*1
Professional Service Line Item Details: SV1*HC:99213*50*UN*1***1
SV101-01 Procedure Code Qualifier: ‘HC’ HCPCS
SV101-02 Procedure Code: 99213
SV102 Procedure Amount: $50
SV103 Unit of Measure Code: ‘UN’ Units
SV104 Service Unit Count: 1
SV107-01 1st Diagnosis Code Pointer: 1
Date or Time or Period: DTP*472*D8*20120124
Date/Time Qualifier : ’472′ Service
Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD
Date Time Period : 20120124
Service Line Number 2: LX*2
Professional Service Line Item Details: SV1*HC:87046*15*UN*1***1:2:3:4
SV101-01 Procedure Code Qualifier: ‘HC’ HCPCS
SV101-02 Procedure Code: 87046
SV102 Procedure Amount: $15
SV103 Unit of Measure Code: ‘UN’ Units
SV104 Service Unit Count: 1
SV107-01 1st Diagnosis Code Pointer: 1
SV107-02 2nd Diagnosis Code Pointer: 2
SV107-03 3rd Diagnosis Code Pointer: 3
SV107-04 4th Diagnosis Code Pointer: 4
Date or Time or Period: DTP*472*D8*20120124
Date/Time Qualifier : ’472′ Service
Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD
Date Time Period : 20120124
837 Deciphering Raw Data 2420C
LOOP 2420C SERVICE FACILITY LOCATION NAME
Billing Provider Information: NM1*77*2*BEST LAB COMPANY*****XX*1124157821
NM101 Entity Identifier Code : Service Location “77″
NM102 Entity Type Qualifier : Non-Person Entity “2″
NM103 Organization Name : BEST LAB COMPANY
NM108 Identification Code Qualifier : National Provider Identifier “XX”
NM109 NPI: 1134125736
Service Facility Address: N3*505 Main Street
N301 Street Address: 505 Main Street
Billing Provider City, State, ZIP Code: N4*ANAHEIM*CA*92802
N401 City: ANAHEIM
N402 State: CA
N403 Zip: 92802
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