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X12 EDI Examples
EDI 837 Professional. Version 005010X222A1
Example 1: Outpatient Visit
Example 2: Claim level Attachment (PWK) Example.
Example 3: Claim with Referring Provider example.
Example 4: Claim with Pay to Address example.
Example 5: Claim for Ambulance service.
Example 6: Claim with Prior Authorization Number.
Example 7: Claim with Payer Claim Number.
Example 8: Billing Provider Secondary identification.
Example 9: Facility with Secondary identification.
Example 10: Billing Laboratory Claims Electronically
Example 11: Payer with secondary identification
Example 12: Billing Provider Complete information
Example 13: Patient is a different person than the Subscriber
Example 14: K3 File Information
Example 15 : Claim Note NTE Segment
Example 16 : Billing for Physician Administered Drugs and NDC Reporting
EDI 837 Dental . Version 005010X224A2
Example 1: Orthodontic-treatment-plan
Example 2: One Claim with 12 Procedure Codes
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Difference between 277CA and 277
EDI 277 generated by the Payer whereas EDI 277CA generated by clearing house or payer or both. EDI 277CA will be generated as soon as EDI 837 File is passed whereas EDI 277 will be generated only upon request by EDI 276 transaction.
EDI 277CA will provide a claim level acknowledgement such as your claim is accepted or rejected. But it does not guarantee that payment will be made.If accepted, an payer claim number will be generated and the same claim will pass to next level of process in the payer system called adjudication system. EDI 277 will be generated only if the claim is accepted and having an payer claim number. If the claim is rejected at the 277CA level itself, then we cannot check the claim status because that claim is not in the payer adjudication system.
Today, many insurance companies respond to claims using their own report formats and/or electronic transaction formats. The ASC X12 277CA offers a common interface to the insurance company and the provider, thus standardizing the response. Because a claim may progress through several different statuses before reaching a final processing disposition, a provider may receive multiple ASC X12 277CA transactions for a single claim.
Sample EDI 277CA
ISA*00* *00* *ZZ*XXXXXXX *ZZ*9085 *210301*1322*%*00501*000000000*0*P*:
GS*HN*XXXXXXX*9085*20210301*132234*1*X*005010X214
ST*277*0001*005010X214
BHT*0085*08*0001*20210301*132234*TH
HL*1**20*1
NM1*AY*2*XXXXX.XXXXXX*****46*XXXXX
TRN*1*000000001
DTP*050*D8*20210301
DTP*009*D8*20210301
HL*2*1*21*1
NM1*41*2*XXXXXX XXXXX LLC-TEST ACCOUNT*****46*9085
TRN*2*0001
STC*A1:19*20210301*WQ*120
HL*3*2*19*1
NM1*85*2*DEMO CLINIC*****XX*1215099528
TRN*1*0
HL*4*3*PT
NM1*QC*1*XXXXX*XXXXX****MI*XYZ312322
TRN*2*124309
STC*A7:21*20210301*U*120********Rendering NPI Fails LUHN check.
DTP*472*D8*20190604
SE*20*0001
GE*1*1
IEA*1*000000000
Payer Claim Number aka Internal Control Number (ICN) or Claim Control Number (CCN)
A Payer Claim Number, also known as an Internal Control Number (ICN), Claim Control Number (CCN), or Document Control Number (DCN), is a unique identifier assigned by a payer to track a claim within their internal system.
Significance of the Payer Claim Number in Claim ProcessingTo fully understand the role of this number, let’s go through the typical claim processing workflow:
- Healthcare entities such as provider offices, facilities, hospitals, and laboratories generate claims for patients and submit them to payers via Electronic Data Interchange (EDI) or paper claims (CMS-1500 form).
- Upon receipt, the payer validates the claim, performs necessary error checks, and enters the claim into their internal processing system. At this stage, a unique claim number is generated for future reference.
- The payer then determines their financial responsibility through a process known as claims adjudication. The claim may be approved for full payment, partially paid, or denied based on coverage and policy rules.
- An Explanation of Benefits (EOB) is then issued to the provider, detailing the payment decision and any applicable denial reason codes. The payer includes the Payer Claim Number in both the EOB (paper format) and the Electronic Remittance Advice (EDI 835).
When a claim is denied, the healthcare provider must correct and resubmit it for reconsideration. In this process, the inclusion of the original Payer Claim Number—as provided in the EOB or EDI 835—is mandatory.
This number allows the payer’s system to quickly recognize that the claim is a resubmission rather than a new claim, facilitating efficient processing. Most payers will not accept resubmissions that do not reference the original Payer Claim Number.
For detailed submission guidelines, refer to specific payer instructions such as the BlueCross BlueShield resubmission policy, which mandates the inclusion of the Payer Claim Number.
How to Retrieve the Payer Claim Number from an ERA 835 FileThe Payer Claim Number can be located in the CLP segment of the ERA 835 file at the 7th position. Below is an example:
TS3*003448478501*12*20201231*2*96 CLP*143155*19*48*0**HM*20C783340200*12*1 NM1*QC*1*XXXXX*XXXXX M*M***MI*521106302
In this case, 20C783340200 is the Payer Claim Number.
Best Practices for Recording the Payer Claim Number in PMS SoftwareMost Practice Management Software (PMS) solutions include a designated field for entering the Payer Claim Number during manual payment posting. However, payment posters often overlook this field, leading to inefficiencies in claim tracking.
To ensure accuracy:
- Train payment posting teams on the importance of capturing this number.
- Implement a system validation that requires entry of the Payer Claim Number when processing denied claims.
- For claims with zero payments, enforce the entry of both denial codes and the Payer Claim Number before finalizing the posting.
When resubmitting a claim via EDI 837P, the Payer Claim Number must be inserted in Loop 2300 REF Segment. Below is a sample format:
CLM*214170*64.00***12:B:7*Y*A*Y*Y REF*F8*185274314700919
Here, REF*F8*185274314700919 references the original Payer Claim Number within the EDI 837P file.
ConclusionBy ensuring that the Payer Claim Number is accurately recorded and referenced during claim resubmissions, healthcare providers can significantly improve the efficiency of their claim processing and reduce unnecessary denials. Compliance with payer-specific guidelines is key to seamless reimbursement.
Understanding X12 EDI Structure
Understanding EDI Structure
Introduction
Before diving into the EDI (Electronic Data Interchange) structure, let's first understand how data is typically structured in a book or a Word document.
Structure of a Page
- Word: A single unit of language separated by space.
- Sentence: A group of words forming a meaningful statement.
- Paragraph: A collection of sentences expressing a complete idea.
Example of Address Representation
Subscriber Information
Carrie J. Brown, DOB 01/13/1953, Male 3360 Lynn Street Woburn, MA 01801
Company Information
Healthservices LLC, Tax ID: xx1234512 2550 Adamsville Road Harlingen, TX 78550
Page vs. EDI Structure
| Traditional Document | EDI Structure |
|---|---|
| Words are separated by spaces | Elements are separated by a delimiter (usually *) |
| Sentences are separated by lines | Segments are separated by a terminator (usually ~) |
| Paragraphs are separated by line breaks | Loops do not have defined separators |
Converting Data to EDI Format
Using EDI formatting, the above address example is converted into:
Carrie*J*Brown*01/13/1953*Male~ 3360*Lynn Street~ Woburn*MA*01801~ Healthservices LLC*xx1234512~ 2550*Adamsville Road~ Harlingen*TX*78550~
Note: In real-world EDI, this appears as:
Carrie*J*Brown*01/13/1953*Male~3360*Lynn Street~Woburn*MA*01801~Healthservices LLC*xx1234512~2550*Adamsville Road~Harlingen*TX*78550~
How Computers Process EDI Data
Computers do not inherently understand the meaning of raw EDI data. To structure it properly, we use:
- Segment Name - Identifies the type of data.
- Type Qualifier (Optional) - Specifies what the segment represents.
Rewriting the Example with Proper EDI Segments
NM1*IL*Carrie*J*Brown*01/13/1953*Male~ N3*3360*Lynn Street~ N4*Woburn*MA*01801~ NM1*85*Healthservices LLC*xx1234512~ N3*2550*Adamsville Road~ N4*Harlingen*TX*78550~
Key Points
- ✅ Each segment starts with a segment name (e.g., NM1, N3, N4).
- ✅ Type qualifiers (e.g., IL, 85) differentiate data types.
- ✅ Address segments (N3, N4) do not require a type qualifier.
Additional Notes on EDI Messages
- If you need to send a number (NPI, Tax ID, SSN), it must be prefixed with an identifier.
NM1*85*2*Demo Clinic*XX*1215099528
Since segments are groups of elements, some elements may be optional.
- With a middle name:
NM1*IL*Carrie*J*Brown
- Without a middle name:
NM1*IL*Carrie**Brown
Conclusion
EDI structures transform unstructured text into computer-readable formats. By using segments, delimiters, and type qualifiers, we create a standardized way to exchange data efficiently.
Before Jumping to EDI Structure, let us understand what is a Page in a book or word document?
Structure of the Page| Word | A word is a single unit of language that can be represented in writing or speech and each word is separated by space. |
| Sentence | A combination of a group of words that gives a complete meaning and each sentence separated by a line |
| Paragraph | A combination of a group of sentences that gives a complete meaning |
Let us name the below paragraph as Paragraph 1 and contains Subscriber information.
Carrie J. Brown, DOB 01/13/1953, Male
3360 Lynn Street
Woburn, MA 01801
Let us name the above paragraph as Paragraph 2 and contains Company information with a tax id.
Healthservices LLC, Tax ID: xx1234512
2550 Adamsville Road
Harlingen, TX 78550
Page Vs EDI
| Page in a Book | Message in an EDI |
| Word | Elements |
| Sentence | Segments |
| Paragraph | Loop |
| Page in a Book | Message in an EDI |
| Words are separated by space | Elements as separated by a delimiter. Any Character can be a delimiter, but most used is Asterisk * |
| Sentence are separated by Line | Segments as separated by the terminator. Any character can be terminator, but most used is ~ |
| Paragraph are separated by one or more lines | There are no separators for Loop |
Carrie*J*Brown*01/13/1953*Male~
3360*Lynn Street~
Woburn*MA*01801~
Healthservices LLC*xx1234512~
2550*Adamsville Road~
Harlingen*TX*78550~
Just for better understanding, the above information is separated with a newline character, but in real-time, it will look as follows
Carrie*J*Brown*01/13/1953*Male~3360*Lynn Street~Woburn*MA*01801~Healthservices LLC*xx1234512~2550*Adamsville Road~Harlingen*TX*78550~
Now let us get into more detail by looking at the above message. There are some issues for the computer to understand as follows.
1) Very first, the computer does not know what we are talking about, but we know that the above is two address representations where one is for the subscriber and one is for the company.
2) So, it is time to give information in a more structured way to the computer about this data.
X12 EDI expects before you start giving information, it needs a segment Name and segment type. Whenever we need to provide information about an entity or person, then the segment name is NM1. Second, we need to inform what is that entity or person, are its Patient details or is it Company Name, etc. That is called type qualifier, for example, for the subscriber, the type qualifier is IL and for Company, the type qualifier is 85, etc
Segments should start with Segment Name, optionally there should be segment type or type qualifier.
Let us rewrite our examples in EDI Structure
NM1*IL*Carrie*J*Brown*01/13/1953*Male~
N3*3360*Lynn Street~
N4*Woburn*MA*01801~
NM1*85*Healthservices LLC*xx1234512~
N3*2550*Adamsville Road~
N4*Harlingen*TX*78550~
As you can see, every segment starts with segment names such as NM1, N3, N4, etc and optionally it also contains type in the second position. An important point to note that is, for address segments, there is no need to provide type.
Other important notes on EDI Message
1) If you want to send any number such as NPI or tax ID or SSN, then before that number we need to tell what that number is. For example, the provider contains NPI number, so before we put the actual NPI number, it should be prefixed by XX as follows1) If you want to send any number such as NPI or tax ID or SSN, then before that number we need to tell what that number is. For example, provider contains NPI number, so before we put the actual NPI number, it should be prefixed by XX as followsNM1*85*2*Demo Clinic*XX*1215099528
Provider Identifiers
What is Controlled Medication