What does the Build Health Care Claim EDI (X12 837) skill do?

Convert a patient encounter into an ASC X12N 837 health care claim (837P 005010X222A1 / 837I X223A2 / 837D X224A2) — ISA/GS/ST envelope, hierarchical billing/subscriber/claim/service loops, NPI/ICD-10-CM/CPT-HCPCS mapping, diagnosis pointers, charge reconciliation, COB, and a worked 837P example

How do I run the Build Health Care Claim EDI (X12 837) skill?

Copy the skill and paste it into your own Claude or ChatGPT, then provide your source data. FinchContext skills run inside your own AI assistant, so your financial data never leaves your control.

Which region does the Build Health Care Claim EDI (X12 837) skill cover?

United States. It targets the local tax authority / e-invoicing format described on this page.

Build Health Care Claim EDI (X12 837)

Skill: Convert a patient encounter into an X12 837 health care claim

Region: United States Category: Health Care EDI (HIPAA X12 5010) Does: Takes a provider's patient-encounter and billing data and assembles the ASC X12N 837 Health Care Claim EDI transaction — the HIPAA-mandated electronic format providers send to payers (and clearinghouses) to bill professional, institutional, or dental services. Spec: ASC X12 005010 — 837P 005010X222A1 (Professional) · 837I 005010X223A2 (Institutional) · 837D 005010X224A2 (Dental)

837 is mandated under HIPAA for electronic claims and is governed by the X12 Technical Report Type 3 (TR3 / Implementation Guide) for the variant. Loop/segment IDs below are the standard 5010 structure; the TR3 is the authority for usage, situational rules, and code sets — always validate against the correct variant's TR3. Trading partners also impose companion guides (payer-specific) on top of the TR3.

Transaction envelope

ISA  Interchange Control Header        (authorization, sender/receiver IDs, control no.)
 GS  Functional Group Header           (HC = health care claim, version 005010X222A1)
  ST  Transaction Set Header           (837)
   BHT Beginning of Hierarchical Transaction
   ... loops below ...
  SE  Transaction Set Trailer          (segment count, control no.)
 GE  Functional Group Trailer
IEA  Interchange Control Trailer

ISA/IEA and GS/GE are the interchange/group envelopes; ST/SE wraps one 837. Element separator, sub-element separator, and segment terminator are declared in ISA.

Hierarchical loop structure (837P)

1000A  Submitter Name (NM1·41)            + PER contact
1000B  Receiver Name  (NM1·40)
2000A  Billing Provider HL                (PRV taxonomy, CUR)
  2010AA Billing Provider Name/Address    (NM1·85, N3/N4, REF EIN/NPI)
  2010AB Pay-to Address (situational)
  2000B  Subscriber HL                     (SBR — payer responsibility, group)
    2010BA Subscriber Name (NM1·IL)        + DMG demographics
    2010BB Payer Name (NM1·PR)
    2000C  Patient HL (only if patient ≠ subscriber)
    2300   CLAIM                           (CLM, DTP dates, HI diagnosis codes)
      2310x Rendering / Service-facility / Referring providers
      2320  Other subscriber / COB         (AMT, OI, CAS prior-payer adjustments)
      2400  SERVICE LINE                    (LX, SV1 procedure+charge, DTP, REF)

837I uses revenue codes + bill type (CLM/SV2); 837D uses dental (SV3) — same envelope, different service-line and code sets.

Key segments

Segment	Carries
`BHT`	claim or encounter purpose, originator app, creation date/time
`NM1`	a named entity — qualifier sets the role (`85` billing, `IL` subscriber, `PR` payer, `82` rendering) + NPI
`SBR`	payer responsibility sequence (P/S/T), relationship, group/plan
`CLM`	claim ID, total charge, place of service, provider signature/assignment indicators
`HI`	diagnosis codes (ICD-10-CM, pointer order matters)
`SV1`	professional service: HCPCS/CPT procedure + modifiers, line charge, units, diagnosis pointers
`DTP`	service / admission / accident dates
`REF`	identifiers (EIN, prior auth, claim control number)

Data rules

NPI (10-digit National Provider Identifier) identifies providers; the subscriber/patient carry the member ID; payer carries the Payer ID.
Diagnosis = ICD-10-CM in HI; procedures = CPT/HCPCS with modifiers in SV1 (837P) — line-level diagnosis pointers map each service line to the HI diagnoses by position.
Claim charge (CLM02) must equal the sum of the service-line charges (SV1 line amounts) within the claim.
Coordination of benefits (secondary claims) carries the prior payer's adjustments in CAS and paid amount in AMT within loop 2320/2430; balances must reconcile to the prior payer's 835.
SE segment count must equal the actual number of segments from ST to SE inclusive; control numbers in ISA/IEA, GS/GE, ST/SE must match their trailers.

Worked example (837P, one office visit — skeleton)

ISA*00*          *00*          *ZZ*SUBMITTERID    *ZZ*PAYERID        *250531*1200*^*00501*000000001*0*P*:~
GS*HC*SUBMITTERID*PAYERID*20250531*1200*1*X*005010X222A1~
ST*837*0001*005010X222A1~
BHT*0019*00*REF123*20250531*1200*CH~
NM1*41*2*ACME BILLING*****46*SUBMITTERID~
NM1*40*2*BCBS*****46*PAYERID~
HL*1**20*1~
NM1*85*2*FAMILY CLINIC PA*****XX*1234567893~   (Billing provider, NPI)
HL*2*1*22*0~
SBR*P*18*******CI~
NM1*IL*1*DOE*JANE****MI*MEMBER123~              (Subscriber/member)
NM1*PR*2*BCBS*****PI*PAYERID~
CLM*PATCTL001*125***11:B:1*Y*A*Y*Y~            (Claim, total charge 125.00, POS 11)
HI*ABK:J0190~                                   (ICD-10-CM diagnosis)
LX*1~
SV1*HC:99213*125*UN*1***1~                      (CPT 99213, charge 125.00, dx pointer 1)
DTP*472*D8*20250531~                            (service date)
SE*16*0001~
GE*1*1~
IEA*1*000000001~

(Single line charge 125.00 = CLM02 total; SE count = number of segments ST…SE.)

Validation checklist

Correct variant TR3 used (837P X222A1 / 837I X223A2 / 837D X224A2) + payer companion guide
ISA/GS/ST envelope IDs, version, and control numbers match their trailers; SE segment count correct
Billing/rendering provider NPIs present; subscriber member ID and payer ID correct
Diagnoses are ICD-10-CM (HI); services are CPT/HCPCS with valid modifiers (SV1)
Diagnosis pointers on each service line reference existing HI positions
Claim charge = Σ service-line charges; units and dates present
COB/secondary claims carry prior-payer CAS/AMT reconciling to the 835
Delimiters consistent; file passes a 5010 X12/HIPAA validator before transmission

Last updated: 2026-05-31 — verify the exact loop/segment usage, situational rules, and code sets against the current ASC X12 005010 TR3 for the 837 variant (P/I/D) and the payer's companion guide before use.