Healthcare EDI Decoded: The 837 Claim and 835 Payment

Introduction

In US Healthcare, the Health Insurance Portability and Accountability Act (HIPAA) mandates the use of specific EDI X12 standards for exchanging information between Providers (Doctors/Hospitals) and Payers (Insurance Companies).

1. EDI 837: Health Care Claim

The 837 is the electronic file submitted to the insurance company to request payment for medical services. There are three main versions:

• 837P (Professional): For doctors and clinics.
• 837I (Institutional): For hospitals.
• 837D (Dental): For dentists.

X12 Sample (837 Professional)

An 837 file is hierarchical (Provider -> Subscriber -> Patient -> Diagnosis -> Service Line).

Copy
1ST*837*0001*005010X222A1~
2BHT*0019*00*CLAIM123*20250912*1200*CH~
3NM1*41*2*SMITH*JOHN****46*1234567890~ (Submitter/Provider)
4NM1*40*2*BLUE CROSS****46*PAYERID~ (Receiver/Payer)
5HL*1**20*1~ (Information Source)
6HL*2*1*22*0~ (Subscriber)
7CLM*PATIENT_ACCT_123*150.00***11:B:1*Y*A*Y*Y~ (Claim Info)
8HI*ABK:A001~ (Diagnosis Code - ICD-10)
9LX*1~
10SV1*HC:99213*150.00*UN*1***1~ (Service Line - CPT Code)
11DTP*472*D8*20250910~ (Date of Service)
12SE*25*0001~

2. EDI 835: Health Care Claim Payment/Advice (ERA)

Direction: Payer -> Provider The 835 explains the payment. It details what was paid, denied, or adjusted (e.g., "Patient has a $20 copay"). It drives the "Auto-Posting" process in hospital billing systems.

X12 Sample (835)

Copy
1ST*835*0001~
2BPR*I*130.00*C*ACH*CCP*01*999999999**1999999999**DA*0001234567~ (Payment Info)
3TRN*1*CHECK12345*1999999999~
4N1*PR*BLUE CROSS~
5CLP*PATIENT_ACCT_123*1*150.00*130.00*20.00*MB*1234567890~ (Claim Level Payment)
6CAS*PR*1*20.00~ (Adjustment: $20 Deductible)
7SVC*HC:99213*150.00*130.00~
8SE*20*0001~

3. EDI 999: Implementation Acknowledgment

Before a claim is processed, the standard "Technical Ack" (999) confirms the file was received and passed syntax validation (e.g., no missing mandatory fields).

Conclusion

Healthcare EDI is rigorous. A single missing field (like an NPI number or Diagnosis pointer) results in a rejection. Modern clearinghouses automate this, but understanding the raw 837 data is essential for debugging claim denials.