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 Note (NTE) Segment which can be used for communicating such messages
At the claim level, we can use the following any of the following as note code reference.
ADD Additional Information
CER Certification Narrative
DCP Goals, Rehabilitation Potential, or Discharge Plans
DGN Diagnosis Description
TPO Third Party Organization Notes
At the line item level, we can use the following any of the following as note code reference.
ADD Additional Information
DCP Goals, Rehabilitation Potential, or Discharge Plans
Example 1 : Claim Level Note
Please note : All the information used in this example are dummy data.
ISA*00* *00* *ZZ*123123 *ZZ*241232 *220530*0637*^*00501*292232520*1*T*:
GS*HC*123123*241232*20220530*0637*29223252*X*005010X222A1
ST*837*0001*005010X222A1
BHT*0019*00*29223252*20220530*0637*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*20201204*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
NTE*CER*CER Certification Info goes here
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*20201204
REF*6R*6001
LX*2
SV1*HC:87070*50*UN*1***1:2
DTP*472*D8*20201204
REF*6R*6002
SE*36*0001
GE*1*29223252
IEA*1*292232520
Please note : All the information used in this example are dummy data.
ISA*00* *00* *ZZ*111134 *ZZ*zirmed *220530*0637*^*00501*796000000*0*P*:
GS*HC*111134*zirmed*20220530*0637*796000000*X*005010X222A1
ST*837*0001*005010X222A1
BHT*0019*00*0001*20220530*0637*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*Simmons*Foster****MI*Y333RF3333
N3*8367 ALIQUAM ROAD*AP #117-8770
N4*Sugar 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
HI*ABK:A05
NM1*82*1*Sean*Smith****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*D8*20190517
REF*6R*75965
NTE*DCP*DCP goes here
NTE*TPO*Addtional Notes goes here
SE*32*0001
GE*1*796000000
IEA*1*796000000
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