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X12 837 Q1 PROFESSIONAL HEALTH CARE CLAIM TRANSACTIONS


EDI 837-Q1 SPECIFICATION

This Draft Standard for Trial Use contains the format and establishes the data
contents of the Health Care Claim Transaction Set (837) for use within the
context of an Electronic Data Interchange (EDI) environment. This transaction
set can be used to submit health care claim billing information, encounter
information, or both, from providers of health care services to payers, either
directly or via intermediary billers and claims clearinghouses. It can also be
used to transmit health care claims and billing payment information between
payers with different payment responsibilities where coordination of benefits is
required or between payers and regulatory agencies to monitor the rendering,
billing, and/or payment of health care services within a specific health
care/insurance industry segment. For purposes of this standard, providers of
health care products or services may include entities such as physicians,
hospitals and other medical facilities or suppliers, dentists, and pharmacies,
and entities providing medical information to meet regulatory requirements. The
payer refers to a third party entity that pays claims or administers the
insurance product or benefit or both. For example, a payer may be an insurance
company, health maintenance organization (HMO), preferred provider organization
(PPO), government agency (Medicare, Medicaid, Civilian Health and Medical
Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third
party administrator (TPA) or third party organization (TPO) that may be
contracted by one of those groups. A regulatory agency is an entity responsible,
by law or rule, for administering and monitoring a statutory benefits program or
a specific health care/insurance industry segment.


SOURCES

Accredited Standards Committee X12. ASC X12 Standard [Table Data]. Data
Interchange Standards Association, Inc., Falls Church, VA. http://www.x12.org


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