837 Institutional Health Care Claim

837 Institutional Health Care Claim Mapping Guidelines (SummaCare)

After the claim transmissions have passed Implementation Guide compliance checks for acceptance into the SummaCare system, business edits, specific to SummaCare, are then applied to the incoming HIPAA compliant claims. The business edits include security validation and the verification of proprietary business requirements. Guidelines are used in conjunction with the ASC X12N 837 Implementation Guide (837 IG) for Institutional Claims. All alpha characters should be formatted as UPPERCASE only.

837 Institutional Health Care Claim – Header

The 837 Header identifies the start of a transaction, the specific transaction set, and the transaction’s business purpose. Also, when a transaction set uses a hierarchical data structure, a data element in the header, BHT01 (Hierarchical Structure Code) relates the type of business data expected within each level.

837 Institutional Health Care Claim – Detail

The 837 Detail level has a hierarchical level (HL) structure based on the participants involved in the transaction. The three levels for the participant types include:

  • Information Source (Billing provider)
  • Subscriber (can be the patient when the subscriber is the patient)
  • Dependent (when the patient is not the subscriber)

837 Detail: Information Source/Provider Hierarchical Level

The first hierarchical level (HL) of the 837 details is the Information Source HL, also known as the Billing/Pay-to Provider HL.

837 Detail: Subscriber Hierarchical Level

The second hierarchical level (HL) of the 837 detail is the Subscriber HL. SummaCare encourages trading partners to submit one claim per transaction set (ST-SE) to eliminate the impact of errors on other clean claims within the same interchange; our X12 and HIPAA compliance edits will reject the entire transaction set if an error is found.

837 Detail: Patient Hierarchical Level

The third hierarchical level (HL) of the 837 detail is the Patient HL. SummaCare encourages trading partners to submit one claim per transaction set (ST-SE) to eliminate the impact of errors on other clean claims within the same interchange; our X12 and HIPAA compliance edits will reject the entire transaction set if an error is found.

To learn more about HIPAA EDI and become a certified EDI Professional please visit our course schedule page.

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