EDI 837 Professional. Version 005010X222A1
In some cases, additional message or notes need to be communicated with the payer. The 837 format has a Claim Level and Claim Line Level File Information segment (“K3”) which can be used for communicating such messages. The K3 segment can repeat up to 10 times.
Example 1 : Claim Level K3 Segment
Please note : All the information used in this example are dummy data.
ISA*00* *00* *ZZ*111134 *01*zirmed *200219*0749*^*00501*796000000*0*P*:
GS*HC*111134*zirmed*20200219*0749*796*X*005010X222A1
ST*837*0001*005010X222A1
BHT*0019*00*0001*20200219*0749*CH
NM1*41*2*Demo Practice*****46*111134
PER*IC*William Richard*TE*2025550170*FX*2025550179
NM1*40*2*zirmed*****46*zirmed
HL*1**20*1
NM1*85*2*Demo Clinic*****XX*1215099528
N3*2486 NORTH UNIVERSITY DRIVE*APT E10
N4*WestField*NY*14787
REF*EI*222222222
HL*2*1*22*0
SBR*P*18*K34532*GFAMPLAN*****BL
NM1*IL*1*XXXXX*XXXXX****MI*XXXXXX
N3*8367 ALIQUAM ROAD*AP #117-8770
N4*XXXX land*CA*743434232
DMG*D8*19451123*M
NM1*PR*2*Blue Choice*****PI*9393
N3*4787 BLUFF STREET
N4*Blue bell*TX*74102
CLM*124304*60***11:B:1*Y*A*Y*Y*P
K3*File Information 1 goes here
K3*File Information 2 goes here
HI*ABK:A05
NM1*82*1*XXXXX*XXXX****XX*6565656565
NM1*77*2*NY Office*****XX*1336177328
N3*5081 Tellus. Avenue
N4*White Plains*NY*809051232
LX*1
SV1*HC:99214*60*UN*1*11**1
DTP*472*RD8*20190517-20190517
REF*6R*75965
SE*32*0001
GE*1*796
IEA*1*796000000
Example 2 : Line Item Level K3 Segment
Please note : All the information used in this example are dummy data.
ISA*00* *00* *ZZ*123123 *ZZ*241232 *220528*1046*^*00501*298522000*1*T*:
GS*HC*123123*241232*20220528*1046*298522*X*005010X222A1
ST*837*0001*005010X222A1
BHT*0019*00*298522*20220528*1046*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***11:B:1*Y*A*Y*Y*Y
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*UN*1***1:2
DTP*472*D8*20201203
REF*6R*6001
K3*Line Item 1 File Information 1 goes here
K3*Line Item 1 File Information 2 goes here
LX*2
SV1*HC:87070*50*UN*1***1:2
DTP*472*D8*20201203
REF*6R*6002
K3*Line Item 2 File Information 1 goes here
K3*Line Item 2 File Information 2 goes here
SE*39*0001
GE*1*298522
IEA*1*298522000
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