When you receive a rejection or denial from a payer, they often speak in terms of loops, segments, and elements. This refers to the coding of the 837 EDI file that was sent to them. Every EDI file is different, but this article can give you a general idea of what you're actually looking at. First, you'll need to know how to find the file itself.
- Navigate to Filing > CMS-1500.
- Find the electronic claim you want to view and select the
icon. - Click View EDI File.
Loops
A block or section of an EDI file is called a Loop. Each loop contains several different Segments, which are comprised of Elements and Sub-Elements.
Although Loops are the biggest component in an EDI, they are often the hardest to distinguish. They will typically begin with an HL or NM1 Segment. While there are several different Loops, they can be broken into 5 main sections:
- 2000A = Billing Provider
- 2000B = Subscriber
- 2000C = Client (Only present if different from Subscriber)
- 2300 = Claim Information
- 2400 = Service Line Information
Note: This is the basic format of an EDI file for a primary payer. There are payers that have very specific requirements that will cause additional loops and segments to be included. Some of those loops and segments are detailed in additional articles linked below.
Segments
The application separates each Segment onto its own line. This makes it a lot easier to read. You'll also notice that each line ends with a tilde (~). This is considered a Segment Separator. Every segment begins with a Segment Identifier Code.
Common codes that you will see throughout the file include:
- PRV = Provider
- SBR = Subscriber
- HL = Hierarchy
- NM1 = Name
- N3 = Street Address
- N4 = City, State, and ZIP
- DTP = Date
- DMG = Demographic
- REF = Reference
- CLM = Claim
- LX = Line
- SV1 = Service
Elements
Within each Segment, you will see several asterisks (*). These are called Element Separators. Additionally, Sub-Elements are separated using a colon (:). If you see multiple asterisks or colons side-by-side, that means that the Element or Sub-Element is empty.
As with Segments, there are also several Element Identifier Codes that you will see throughout the file, such as:
- 41 = Claim Creator (Hardcoded to EI Assistant)
- 40 = Claim Receiver
- 85 = Billing Provider
- 82 = Rendering Provider
- DN = Referring Provider
- IC = Information Contact
- 77 = Service Location
- 472 = Date of Service
- SY = Social Security Number
- EI = Tax ID (EIN)
- XX = NPI
- Y4 = Claim Casualty Number
- HC = Standard CPT Code
- ABK = Principal Diagnosis
- ABF = Diagnosis
Each Element is named using a 2-digit number, and Sub-Elements use a single digit.
Elements and Sub-Elements are attached to the Segment Identifier Code when being referenced.
Example: Loop 2300, HI02-1
- HI = Segment Identifier Code
- 02 = Element
- 1 = Sub-Element
Ready to learn more?
When you have grasped the basic structure of the EDI file, you will want to break down each loop and segment so you know exactly what you are looking at and how to correlates to a CMS-1500 form. For more information, please see:
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