837 Professional Health Care Claim Basic Technical Instructions For Anthem Partners
837 Professional Health Care Claim section provides information to help Anthem partners prepare for the ANSI ASC X12N 837 Professional Health Care Claim transaction. The information given in the blog must be used in conjunction with both the Transaction Set Implementation Guide “Health Care Claim: Professional, 837, ASC X12N 837 (004010X098),” May 2000, and the subsequent Addenda (004010X098A1), October 2002, published by the Washington Publishing Co.
X12 and HIPAA Compliance Checking, and Business Edits
Level 1. The East Region returns a 997 Functional Acknowledgment to the submitter for every inbound 837 Professional Health Care Claim received. Each transaction passes through edits to ensure that it is X12 compliant. If the X12 syntax or any other aspect of the 837 Professional Health Care Claim is not X12 compliant, the 997 Functional Acknowledgment will also report the Level 1 errors in AK segments and indicate that the entire transaction set has been rejected.
Level 2. HIPAA Implementation Guide edits are strictly enforced. In addition, the East Region applies business edits, such as provider and member number validation to each 837 transaction. If a HIPAA compliance, code set or business error is encountered, a Level 2 Status Report will be returned to the submitter indicating the particular claim has failed.
HIPAA Compliant Codes – Follow the 837 Professional IG precisely.
All alpha characters must be submitted in UPPERCASE letters only.
According to the 837 Professional IG (P.254), a transaction is not X12 compliant if decimal points are used in diagnosis codes – Loop 2300 HI Health Care Diagnosis Code. Therefore, should a diagnosis code contain a decimal point, the East Region will return a 997 Functional Acknowledgment to the submitter indicating that the transaction has been rejected.
The East Region accepts any of the standard delimiters as defined by the ANSI standards. The more commonly used delimiters include the following:
- Data Element Separator, Asterisk, (*)
- Sub-Element Separator, Colon, (:)
- Segment Terminator, Tilde (~)
These delimiters are for illustration purposes only and are not specifi c recommendations or requirements.