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Submitting Workers Compensation Claims as 837s

Workers compensation claims contain a special set of requirements when submitted in the EDI 837 format. This article describes these specific characteristics.

  • In a standard 837, the 2000B loop always contains subscriber information (the primary insured individual). Claim level information (2300 loop) is nested beneath the 2000B loop in this scenario. The 2000C (Patient) loop is present in the case in which the claim is related to a dependent of the subscriber. In these cases, the 2300 loop is nested under 2000C. In workers comp claims, a 2000B and 2000C loop always exist, and their purposes are a bit different. Information related to the employer goes into the 2000B loop, while the 2000C loop is used for the claimant (the injured worker). The concept of a dependent doesn’t exist in workers comp claims.
  • The SBR segment present in 2000B is a required field in the 837. It contains information about the payer type and responsibility in coordination of benefits scenarios. In workers comp claims expect SBR09 to carry the specific Claim Filing Indicator code of ‘WC’.

SBR*P********WC~

In workers comp claims, the date of accident (DTP*439) is usually specified as required in companion guides, while the X12 standard marks it situational. Note that the presence of DTP*439 triggers a SNIP 4 rule requiring the inclusion of CLM11. This component value would typically be listed as “EM” for Employment.

  • Although claim attachments are still emerging as a standard in hospital and physician claims, workers comp has typically included a reference to supporting documentation for some time. In these situations, the PWK segment is used to reference the attachment, usually by specifying a filename:

PWK*OZ*EL***AC*GordonShumway.pdf~

In this example, the fields indicate:

PWK01: OZ = Support Data for Claim

PWK02: EL = Electronically Only

PWK05: AC = Attachment Control Number (Conditionally required if PWK02 = EL)

PWK06: Implementation specific. This can reference a control number if submitting an attachment transaction, or may simply represent a file name.

  • The jurisdiction state requirements are important to verify when onboarding trading partners. In general, workers comp claims are paid according to the rules of the state where the accident occurred. Conflicts between state jurisdiction can occur in scenarios where an employee lives outside the state, or the employer’s address is different than the state in which the accident occurred.

Here is a sample de-identified 837P workers comp bill which implements the features mentioned above.

ISA*00* *00* *ZZ*123456789 *ZZ*987654321 *180716*1710*^*00501*000000001*1*T*:~
GS*HC*123456789*987654321*20180716*171054*1*X*005010X222A1~
ST*837*0001*005010X222A1~
BHT*0019*00*000000001*20180716*171054*CH~
NM1*41*2*HEALTH LAB*****46*987654321~
PER*IC*GORDON SHUMWAY*TE*8001233000~
NM1*40*2*TALLAN*****46*987654321~
HL*1**20*1~
PRV*BI*PXC*ABC00000X~
NM1*85*2*HEALTH LAB*****XX*1238887234~
N3*123 MAIN ST~
N4*OVIEDO*FL*32765~
REF*EI*8123456~
HL*2*1*22*1~
SBR*P********WC~
NM1*IL*2*GA STATE EMPLOYER*****II*123624191~
N3*200 SPRUCE ST~
N4*ATLANTA*GA*303340000~
NM1*PR*2*TALLAN*****PI*987654321~
N3*PO BOX 55555~
N4*ALTAMONTE SPRINGS*FL*32716~
HL*3*2*23*0~
PAT*20~
NM1*QC*1*HUBBARD*JOE****MI*123624191~
N3*987 2ND AVE WEST~
N4*REIDSVILLE*GA*30453~
DMG*D8*19750315*M~
REF*SY*123624191~
REF*Y4*WC88783834~
CLM*888888*53.2***11:B:1*Y*A*Y*Y~
DTP*439*D8*20100721~
PWK*OZ*EL***AC*HCFA1500.PDF~
PWK*OZ*EL***AC*SUPPORTDOC.PDF~
HI*ABK:G5601~
NM1*DN*1*ALLEN*FRANK****XX*5436075342~
REF*0B*MD45951~
NM1*82*2*HEALTH LAB*****XX*5435072569~
PRV*PE*PXC*123B00000X~
REF*0B*ZZ99999999999~
NM1*77*2*HEALTH LAB*****XX*1235072568~
N3*123 MAIN ST~
N4*OVIEDO*FL*32765~
LX*1~
SV1*HC:L3908:NU:RT:::SAMPLE DESC*53.2*UN*1***1~
DTP*472*D8*20180712~
SE*44*0001~
GE*1*1~
IEA*1*000000001~

At Tallan, we’re always interested in discussing EDI management challenges. Reach out to us for a consultation to discuss how we can address these challenges within your current infrastructure. Looking to improve other areas of your business? We also discuss a wide variety of topics at our in-person events and webinars

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