EDI 837 Professional. Version 005010X222A1
Example 7: Payer Claim Number
A number assigned by the payer to identify a claim in their internal System. The number is usually referred to as an Internal Control Number (ICN), Claim Control Number (CCN) or a Document Control Number (DCN).
Why this number is needed ?
1) Healthcare entity such as Provider Office, facility, hospital, lab, etc generate the claim for the patient and send to Payer via EDI or CMS 1500.
2) Payer receives the claim, after all the necessary error checking, the claim information will be created into their internal claim processing system. During this process, an unique claim number will be generated in the system for all the future reference.
3) After the claim created in the Payer system , then they determines their financial responsibility for the payment to the provider. This process is referred to as claims adjudication. The insurance company can decide to pay the claim in full, deny the claim, or to reduce the amount paid to the provider.
4) Finally, An explanation of benefits (commonly referred to as an EOB form) is a statement sent to the provider explaining what medical treatments and/or services were paid for on their behalf or why the claim is denied with one or more denied reason codes. Payer specifies their Claim Number both in EOB Paper Form and EDI form (EDI 835).
In case of claim denied, then the servicing entity such as Provider Office, Facility, Hospital, Lab, etc need to correct the claim and re submit the claim again to the Payer. In this process, it is mandatory to include echo back the Payer Claim Number which they they have got from EOB or EDI 835. With this claim Number, payer system can quickly understand that this is existing claim in our process and process the claim and payment can be made.
Please remember, most of the payers will not process your resubmission if you are not putting back their Payer Claim Number.
Here is the EDI File submitted second time after correction (Re submission)
ISA*00* *00* *ZZ*123123 *ZZ*241232 *210512*0450*^*00501*124488000*1*T*:
GS*HC*123123*241232*20210512*0450*124488*X*005010X222A1
ST*837*0001*005010X222A1
BHT*0019*00*0001*20210512*0450*CH
NM1*41*2*ABC Submitter*****46*7342343
PER*IC*John Mike*TE*1214151617
NM1*40*2*Zirmed*****46*12345
HL*1**20*1
PRV*BI*PXC*208500000X
NM1*85*2*Get Well Family Clinic LLC*****XX*1740713692
N3*3937 Kenwood Place
N4*Orlando*FL*32801
REF*EI*81-3777631
HL*2*1*22*0
SBR*P*18*92291223*AED12342*****ZZ
NM1*IL*1*BAKER*Alyssa****MI*723223232
N3*197800 Atascocita Shores Dr*302 12 N. Mcgraw St
N4*HOUSTON*TX*77833
DMG*D8*20201203*M
NM1*PR*2*CIGNA*****PI*81400
N3*PO BOX 660044
N4*DALLAS*TX*75266
CLM*10421*100.00***11:B:7*Y*A*Y*Y*P
REF*F8*XCN6233123
HI*ABK:R1013*ABF:E860
NM1*82*1*Nelson*Romer****XX*1023555349
NM1*77*2*Clinic For Pain And Anxiety *****XX*1396885059
N3*6100 W CREEK RD SUITE 35
N4*Independence*OH*44131
LX*1
SV1*HC:99213*50.00*UN*1.00***1:2
DTP*472*D8*20201203
REF*6R*6001
LX*2
SV1*HC:87070*50.00*UN*1.00***1:2
DTP*472*D8*20201203
REF*6R*6002
SE*36*0001
GE*1*124488
IEA*1*124488000
HTML Version
Interchange Control Header
| Authorization Qualifier | 00 |
| Security Qualifier | 00 |
| Interchange ID Qualifier Sender | ZZ |
| Submitter ID | 123123 |
| Interchange ID Qualifier Receiver | ZZ |
| Receiver ID | 241232 |
| Interchange Date | 05/12/2021 |
| InterChange Time (HHMM) | 04:50 |
| Repetition Seperator | ^ |
| Control Number | 124488000 |
| Acknowledgement Requested | 1 |
| Usage Indicator | T |
Functional Group Header
| Application Sender Code | 123123 |
| Application Receiver Code | 241232 |
| Group Transaction Date | 05/12/2021 |
| Group Transaction Time (HHMM) | 04:50 |
| Group Control Number | 124488 |
| EDI Version | 005010X222A1 |
Transaction Set Header
| Transaction set | 837 |
| Transaction Control Number | 0001 |
Hierarchical Transaction
| Application Transaction Number | 0001 |
| Transaction Date | 05/12/2021 |
| Transaction Time (HHMM) | 04:50 |
| Submitter Entity | Organization |
| Organization Name | ABC Submitter |
| Etin Number | 7342343 |
| Contact Name | John Mike |
| Contact Phone | 1214151617 |
| Receiver Name | Zirmed |
| Receiver Etin Number | 12345 |
Billing Provider
| Entity Type | 2 |
| Last or Organization Name | Get Well Family Clinic LLC |
| Address1 | 3937 Kenwood Place |
| City | Orlando |
| State | FL |
| Zip | 32801 |
| NPI | 1740713692 |
| Tax ID | 81-3777631 |
| Taxonomy Code | 208500000X |
Subscriber information
| Payer Responsbility | P |
| Insured Relationship | 18 |
| Group Number | 92291223 |
| Group Name | AED12342 |
| Claim Filling Indicator | ZZ |
Subscriber Name
| Entity Type | 1 |
| Last or Organization Name | BAKER |
| First Name | Alyssa |
| DOB | 12/03/2020 |
| Gender | M |
| Policy No | 723223232 |
| Address1 | 197800 Atascocita Shores Dr |
| Address2 | 302 12 N. Mcgraw St |
| City | HOUSTON |
| State | TX |
| Zip | 77833 |
Payer
| Name | CIGNA |
| Address1 | PO BOX 660044 |
| City | DALLAS |
| State | TX |
| Zip | 75266 |
| Payer ID | 81400 |
Claim Information
| Claim No | 10421 |
| Billed Amount | 100.00 |
| Claim Type | 7 |
| Provider Sign Indicator | Y |
| Provider Accept Assignment Code | A |
| Benefits Assignment Indicator | Y |
| Release of information | Y |
| Payer Claim Number | XCN6233123 |
ICD Information
| ICD Code 1 | R1013 |
| ICD Code 2 | E860 |
Rendering Provider
| Entity Type | 1 |
| Last or Organization Name | Nelson |
| First Name | Romer |
| NPI | 1023555349 |
Facility
| Name | Clinic For Pain And Anxiety |
| Address1 | 6100 W CREEK RD SUITE 35 |
| City | Independence |
| State | OH |
| Zip | 44131 |
| NPI | 1396885059 |
Line Item : 1
| Line Item ID | 6001 |
| Procedure Code | 99213 |
| Units Code | UN |
| Units | 1.00 |
| Charges | 50.00 |
| ICD Pointers | 1,2 |
| Service From Date | 12/03/2020 |
| Service To Date | 12/03/2020 |
Line Item : 2
| Line Item ID | 6002 |
| Procedure Code | 87070 |
| Units Code | UN |
| Units | 1.00 |
| Charges | 50.00 |
| ICD Pointers | 1,2 |
| Service From Date | 12/03/2020 |
| Service To Date | 12/03/2020 |
CMS 1500 Form Preview for the above EDI File
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