Institutional Claims (837I) JSON

This is the Payer ID. Visit the Payer Network for a complete list. You can send requests using the Primary Payer ID, the Stedi Payer ID, or any alias listed in the payer record.

The entity submitting the healthcare claim. This is an organization, such as a hospital or other treatment center.

The entity responsible for the payment of the claim, such as an insurance company or government agency.

The person or entity who is the primary policyholder for the health plan or a dependent with their own member ID.

• When a dependent has a unique, payer-assigned member ID, treat them as the subscriber for the claim submission - include their information here and omit the dependent object from the request.
• You must set the dateOfBirth and gender properties when the subscriber is the patient. Stedi determines that the subscriber is the patient when the dependent object is not included in the request.
• If either dateOfBirth or gender is set, you must include both properties. You can either include both properties or neither within a single request.

Information about the healthcare claim. Note that the objects and properties marked as required are required for all claims, while others are conditionally required, depending on type of claim and claim circumstances. For example, you must always provide the claimChargeAmount, but you only need to provide the otherSubscriberInformation object in coordination of benefits scenarios. When you include a conditionally required object, you must provide all of its required properties.

Not currently used.

Dependent who received the medical care associated with the claim. When the dependent has their own member ID for the health plan, you should include the dependent's information in the subscriber object instead. To check whether a dependent has a member ID, submit an Eligibility Check to the payer. The payer returns the dependent's member ID in the dependents.memberId property in the response, if present.

Another way to send information for each provider relevant to the claim. This object overwrites the information you send in the billing, referring, rendering, and attending objects. Note that your request must include information about the billing provider either here or within the billing object.

Use for subrogation payment requests. If you include this information, you must also set the claimInformation.otherSubscriberInformation.payerPaidAmount to the amount the payer (for example, Medicaid) actually paid.

Use when the address for payment is different than that of the billing provider for this claim.

Information about the individual with primary responsibility for performing the surgical procedure(s) listed in the claim. Required when a surgical procedure code is listed on the claim. Use this object for operating physicians that apply to the entire claim.

This should be an individual, not an organization, and you should supply at least the physician's lastName and an identifier, which is typically the npi.

Information about any other operating physician involved in the surgical procedures listed in the claim. Required when another operating physician is involved in the surgical procedures listed in the claim. Use this object for physicians that apply to the entire claim.

This should be an individual, not an organization, and you should supply at least the physician's lastName and an identifier, which is typically the npi.

Address information for the entity responsible for payment of the claim, listed in the receiver object.

Whether you want to send a test or production claim. This property also allows you to filter claims in the Stedi portal by production or test data. By default, this property is set to P for production data. Use T to designate a claim as test data.

Information about the billing provider.

• You must include either the provider's Social Security Number (SSN) or their Employer Identification Number (EIN), but not both.
• The provider's National Provider Identifier (NPI) is required, if one is assigned.
• You must also supply the provider's organizationName.

Information about the provider who referred the patient for care.

• Include this object only when the referring provider is different than the provider listed in the attending object.
• Use this object for providers that apply to the entire claim.
• This should be an individual, not an organization, and you should supply at least the provider's lastName and an identifier, which is typically the npi.

Information about the provider who delivered the medical services or non-surgical procedures listed in the claim. This must be an individual, not an organization, and you must supply at least the provider's lastName and an identifier, which is typically the npi. The provider's firstName is also required, if applicable.

Include this object when all of the following are true:

• The rendering provider is different than the provider listed in the attending object.
• The provider applies to the entire claim or to at least one service line. For example, if a claim had two service lines with two different rendering providers, you would include the provider for the first service line here and leave the claimInformation.serviceLines.renderingProvider object for that service line blank. Then, you would specify the second provider in the appropriate service line's claimInformation.serviceLines.renderingProvider object.
• State or federal regulatory requirements call for a combined claim. A combined claim includes both facility and professional components, such as a Medicaid clinic bill or a critical access hospital claim.

Information about the individual who has overall responsibility for the patient's medical care and treatment reported in the claim. This information is required when the claim contains any services other than non-scheduled transportation claims.

This provider should be an individual, not an organization, and you should supply at least the provider's lastName and an identifier, which is typically the npi.

This is the payer's business name, like Cigna or Aetna.

A code specifying the type of transaction. Defaults to CH if not provided.

• 31: Only for use by state Medicaid agencies performing post payment recovery.
• CH: Use when the transaction contains only fee for service claims or claims with at least one chargeable line item. Also use when it's not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters.
• RP: Use for capitated encounters. Also use when the transaction is being sent to an entity for purposes other than adjudication of a claim. For example, when you're sending the claim to a state health agency that is using the claim for health data reporting purposes.

The status of the claim submission.

An identifier for the transaction.

An ID for the payer you identified in the original claim. This value may differ from the tradingPartnerServiceId you submitted in the original request because it reflects the payer's internal concept of their ID, not necessarily the ID Stedi uses to route requests to this payer.

Information about the claim.

A list of errors. Currently not used.

A list of warnings.

A 200 response indicates that Stedi successfully generated the X12 EDI claim format required by the payer. It does not indicate whether the payer has accepted the claim - the payer will respond later with a 277CA containing this information. Learn more about 277CAs. A 400 response indicates one or more problems with the claim data in the request. Examples include missing required fields, invalid values, or incorrect data types. The response includes a message describing the problem.

Metadata from Stedi about the request.

Currently not used.

Currently not used.

Information about the payer for the submitted claim.

Currently not used.