What is an EDI 837-Q1 Health Care Claim: Professional?

One of the X12 transactions, it is used by payers or regulatory agencies for submitting healthcare claim billing details, encounter information, or both. The information exchanged in an EDI 837-Q1 transaction set includes healthcare provider details, patient insurance plan, services provided, and patient’s medical history.

EDI X12 837-Q1 Health Care Claim: Professional Sample

This EDI document set is divided into functional groups that explain the contents of the transaction being conducted. A sample  document looks like this[1].

ISA*00* *00* *01*9012345720000 *01*9088877320000
*100816*1144*U*00200*000000031*0*T*:~
GS*HC*901234572000*908887732000*20100816*1615*31*X*005010X223A1~
ST*837*0034*005010X223A1~
BHT*0019*00*3920394930203*20100816*1615*CH~
NM1*41*2*HOWDEE HOSPITAL*****46*0123456789~
PER*IC*BETTY RUBBLE*TE*9195551111~
NM1*40*2*BCBSNC*****46*987654321~
HL*1**20*1~
NM1*85*2*HOWDEE HOSPITAL*****XX*1245011012~
N3*123 HOWDEE BLVD~
N4*DURHAM*NC*27701~
REF*EI*123456789~
PER*IC*WILMA RUBBLE*TE*9195551111*FX*6145551212~
HL*2*1*22*0~
SBR*P*18*XYZ1234567******BL~
NM1*IL*1*DOUGH*MARY****MI*24672148306~
N3*BOX 12312~
N4*DURHAM*NC*27715~
DMG*D8*19670807*F~
NM1*PR*2*BCBSNC*****PI*987654321~
CLM*2235057*200***13:A:1***A**Y*Y~
DTP*434*RD8*20100730-20100730~
CL1*1*9*01~
REF*F8*ASD0000123~
HI*BK:25000~
HI*BF:78901~
HI*BR:4491:D8:20100730~
HI*BH:41:D8:20100501*BH:27:D8:20100715*BH:33:D8:20100415*BH:C2:D8:20100410~
HI*BE:30:::20~
HI*BG:01~
NM1*71*1*SMITH*ELIZABETH*AL***34*243898989~
REF*1G*P97777~
LX*1~
SV2*0300*HC:81000*120*UN*1~
DTP*472*D8*20100730~
LX*2~
SV2*0320*HC:76092*50*UN*1~
DTP*472*D8*20100730~
LX*3~
SV2*0270*HC:J1120*30*UN*1~
DTP*472*D8*20100730~
SE*38*0034~
GE*1*30~
IEA*1*000000031~

Workflow for the Exchange of an EDI 837-Q1 Health Care Claim: Professional

One of the X12 EDI transactions, EDI 837-Q1 Professional Health Care Claim is commonly used for health data exchange by healthcare providers, payers, and clearinghouses. This transaction set helps improve information access for all parties, thus ensuring reliable claim processing.

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