Electronic Claims File Structure
Compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires the ANSI ASC X12N 837 Health Care Claims (837) transaction for professional claims and/or encounters to contain specific standardized information. The standardization of health care information allows health care providers to submit 837 electronic files within the NextGen In-line Edits environment.
There are three types of 837 electronic files:
- Professional (1500 claim forms)
- Institutional (UB claim forms)
- Dental ADA
Each type has the same basic electronic file structure. The 837 electronic file is structured to deliver control segments of information, which include:
- Interchange Control Segments
- Functional Group Control Segments
- Transaction Control Segments
- Loop Control Segments
- Interchange Acknowledgment Control Segments
Each control segment usually has a beginning header label and an ending trailer label. The table below outlines each of the control segments and their identifying labels.
| Control Segment | Identifying Header Label | Identifying Trailer Label |
|---|---|---|
| Interchange Envelope | ISA – Interchange Control Header | IEA – Interchange Control Trailer |
| Functional Group | GS – Functional Group Header | GE – Functional Group Trailer |
| Transaction Set | ST – Transaction Header | SE – Transaction Trailer |
| Loop Control Segment (Data Segments) | LS – Loop Header | LE – Loop Trailer |
| Interchange Acknowledgment | TA1 – Interchange Acknowledgment | There is no identifying trailer label associated with the TA1. The TA1 is a single control segment. |