EDI 837

How the EDI 837 Works in a Typical Enrollment Process:

The EDI 837 is used after enrollment and payment processing to handle claims submission and reimbursement. It fits in the process when healthcare providers submit claims for services rendered to insured members. The insurer processes these claims and then sends an EDI 835 for payment and explanation of benefits.

• Eligibility Check:
• EDI 270 is sent by the employer or provider to check eligibility.
  EDI 271 is the insurance provider’s response confirming eligibility.
   

• Enrollment Submission:

  The employer submits EDI 834 to enroll or update coverage for employees.
  The insurance provider sends EDI 997 or EDI 999 to acknowledge the receipt of EDI 834.
   

• Premium Payment:

  The employer sends EDI 820 to pay premiums for enrolled members.
   

• Claim Submission (EDI 837):

  EDI 837 is submitted by healthcare providers after services are rendered to request payment from the insurance provider.
  This transaction contains details about the services provided, diagnosis, and charges.
   

• Claim Status Check:

  If needed, the provider sends EDI 276 to check the status of the submitted claim.
  The insurer responds with EDI 277 to provide updates on the claim.
   

• Claim Payment:

  The insurance provider sends EDI 835, showing the details of the claim payment and any adjustments or denials based on the EDI 837.

Key Components of an EDI 837:

• Patient Information: Patient’s name, date of birth, insurance details.
• Provider Information: Healthcare provider’s name, National Provider Identifier (NPI), and billing details.
• Claim Information: Unique claim number and claim type (e.g., professional, institutional).
• Service Information: Procedure codes (CPT/HCPCS), service dates, and any special modifiers.
• Diagnosis Codes: ICD codes for the patient’s condition or reason for services.
• Charge Information: Total charges, amount paid by the insurance, and patient’s share.
• Dates: Date of claim submission and service dates.
• Claim Adjustments: Any reductions or denials to the payment.
• Referral Information: Referral number and referring provider (if applicable).
• Coordination of Benefits: Information on multiple insurance coverage (if applicable).