Doc 837 Health Care Claim
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 render-ing,
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 infor-mation
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 Uni-formed
Services (CHAMPUS), etc.) or an entity such as a third party adminis-trator
(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.
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