Standard Form EDI 837 Files

The EDI 837 is a standardized electronic format used by healthcare providers to submit medical claims to insurance companies or payers. The 837 format is part of the ANSI X12 standard, which is used for transmitting business data electronically.

What is in an 837 File

Think of an 837 File as a letter with 3 different sections. Each of these sections contains vital information necessary to adjudicate a claim. Let's review each section and the information it contains!

Simplified Example

ISA*00*          *00*          *ZZ*PROVIDER1     *ZZ*PAYER1        *230101*1234*^*00501*123456789*0*T*:~
GS*HC*PROVIDER1*PAYER1*230101*1234*123456789*X*005010X222A1~
ST*837*0001*005010X222A1~
1000A*PR*PROVIDER1*XX*123456789*ZZ*PROVIDER1~
2000*82*123456789*12*SUBSCRIBER1~
2300*CLM*1234567*200*11*P*Y*I~
2400*SV1*HC:99213*50*UN*1~
SE*25*0001~
GE*1*123456789~
IEA*1*123456789~

Header Information

Think of the header information as the envelope of an EDI file. It provides the clearinghouse with information about who is sending the claim and receiving it, and control numbers for tracking information. 

Common Header Identifiers 

• The ISA, also known as the Interchange Header, marks the beginning of a file.
• The GS provides the clearinghouse with information about the provider and the payer while grouping related claims. 

Transaction Details

The transaction details provide the contents of our letter and consist of 2 components: the transaction start/end date and the main section.  The main section of an EDI file contains loops and segments. Each loop comprises a group of related information, then broken down into segments within the loop.

Transaction Detail Identifiers 

• Similar to a letter's title, the ST and SE identify the type of claims included in the file, when they begin, and when they end.
  
  • ST (Transaction Set Header): Marks the beginning of a claim transaction.
  • SE (Transaction Set Trailer): Marks the end of the transaction.
• Each loop comprises a group of related information, then broken down into segments within the loop. 
  
  • Loop 1000A: Billing Provider Information - this loop provides information about who is sending the claim (e.g., doctor, hospital).
  • Loop 1000B: Pay-to-Provider Information — contains information about where payment should be sent.
  • Loop 2000: Subscriber (Patient) Information — contains patient demographic information like name, home address, and insurance details.
  • Loop 2300: Claim Information — this loop provides claim data, like the diagnosis, amount billed, and claim number.
  • Loop 2400: Service Line Information — details the services provided, like procedure codes, dates of service, and billed amount for each service.

Footer Information

The footer information provides closing notes marking the end of the transaction, much like the sign-off portion of a letter. 

Common Footer Identifiers 

• The IEA, also known as the Interchange Trailer, marks the end of the file as a whole. 
• The GE, also known as the Functional Group Trailer, marks the end of a group of related claims.