This blog post describes the mapping specifications and the conversion between HIPAA 837 professional and CMS 1500 in PDF format.

This was another one of the 300+ pre-defined HIPAA maps that we have developed in the past. The user can integrate this map into their system with no further work. You can test the map by going to Redix HIPAA Compliance and Conversion Demo.

A blank CMS 1500 form looks like the following.

Mapping Specification

The CMS 1500 form is using the box id to identify the meaning of each field. For example, a patient name is in box 2 and the patient address is in 5. The patient name in a HIPAA 837 professional is defined in 2010BA. Below is a table to describe the box id in the CMS 1500 form and its corresponding element in HIPAA 837 professional.

Search:

CMS 1500 Form Box ID	HIPAA 837 Professional Corresponding Field(s)
1	Checkbox Xwalked from 2000B SBR09
1a	2010BA NM109
2	2010BA NM103-05 overwritten by 2010CA NM103-5 if exists
3	2010BA DMG02, 03 overwritten by 2010CA DMG02, 03 if exists
4	2010BA NM103-05
5	2010BA N3xx, N4xx overwritten by 2010CA N3xx, N4xx if exists
6	Checkbox Xwalked from 2000B SBR02 \| 2000C PAT01
7	2010BA N3xx, N4xx
8	(Internally Used)
9	23230A NM103-05
9a	2320 SBR03
9b	(Internally Used)
9c	(Internally Used)
9d	2320 SBR04
10a	Checkbox Xwalked from 2300 CLM11:01 \| :02 \| :03="EM"
10b	Checkbox Xwalked from 2300 CLM11:01 \| :02 \| :03="AA"
10c	Checkbox Xwalked from 2300 CLM11:01 \| :02 \| :03="OA"
10 (state)	if 2300 CLM11:01 \| :02 \| :03="AA" then CLM11:04
11	2000B SBR03
11a	2010BA DMG02, 03
11b	2000x REF02 (REF01="Y4")
11c	2000B SBR04
11d	Checkbox Xwalked from 2310 Existence
12	Signature Field (Not Mapped)
13	Signature Field (Not Mapped)
14	2300 DTP01, 03 (DTP01="431" \| "438")
15	2300 DTP01, 03 (DTP01="454" \|"304" \| "453" \| "439" \| "455" \| "471" \| "090" \| "091" \| "444")
16	2300 DTP03 (DTP01="360" & "361") concatenated
17	2310A, D NM101, 03-05
17a	2310A REF01-02
17b	2310A, D NM109
18	2300 DTP03 (DTP01="435" & "096") concatenated
19	(reserved for proprietary usage)
20	2300 AMT02 (AMT01="NE"), Checkbox Xwalked from existence of 2310C
21	"9" if HI01:01("BK") exists, else "0"
21A	2300 HI01:02 (HI01:01="BK" \| = "ABK")
21B	2300 HI02:02 (HI01:02="BK" \| = "ABK")
21C	2300 HI03:02 (HI01:03="BK" \| = "ABK")
21D	2300 HI04:02 (HI01:04="BK" \| = "ABK")
21E	2300 HI05:02 (HI01:05="BK" \| = "ABK")
21F	2300 HI06:02 (HI01:06="BK" \| = "ABK")
21G	2300 HI07:02 (HI01:07="BK" \| = "ABK")
21H	2300 HI08:02 (HI01:08="BK" \| = "ABK")
21I	2300 HI09:02 (HI01:09="BK" \| = "ABK")
21K	2300 HI10:02 (HI01:10="BK" \| = "ABK")
21L	2300 HI11:02 (HI01:11="BK" \| = "ABK")
22	2300 CLM05:03 when is "7" \| "8", REF02 (REF01="F8")
23	2300 REF02 (REF01="G1")
24A	2400 DTP03 (DTP01="472")
24B	2400 SV105 \| 2300 CLM05:01
24C	2300 CLM05:03
24D	2400 SV101:02-:06 concatenated
24E	2400 SV107:01-:04 concatenated
24F	2400 SV102
24G	2400 SV104
24H	"Y" if 2400 SV111 \| SV112 are present
24I	(Not mapped, currently assuming NPI is used in 'J')
24J	NM109 (NM108="XX") (2010A is used, overwritten by 2310B if present, ultimately overwritten by 2420A if exists)
25	2010AA REF02 (REF01="EI" \| "24") \| NM109 (NM108<>"XX") \| 2010AB NM109 (NM108<>"XX")
26	2300 CLM01
27	Checkbox Xwalked from CLM07
28	2300 CLM02
29	DNE
30	(Internally Used)
31	Signature Field (Not Mapped)
32	2310C NM103, N3xx, N4xx (If 2310 DNE then same contents from Box 33 are used)
32a	2310C NM109 (If 2310 DNE then same contents from Box 33a are used)
32b	(Not mapped, currently assuming NPI is used in 'A')
33	2010AA NM103, N3xx, N4xx, PER04,06,08 (qual = "TE")
33a	2010AA NM109 (NM108="XX")
32b	(Not mapped, currently assuming NPI is used in 'A')

Showing 1 to 71 of 71 entries

Some of the notes about this conversion:

Validates the input file. Only the file 837 is validated, the file will be converted.
Generates PDF file for each claim.

Example

Below is an 837 professional example:

ISA*00*          *00*          *ZZ*123456789012345*ZZ*123456789012345*030101*1253*^*00501*987654321*1*T*:
GS*HC*123456789012345*123456789012345*19991231*0802*123456789*X*005010X222A1
ST*837*2021*005010X222A1
BHT*0019*00*0123*20051015*1023*CH
NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23
PER*IC*JERRY*TE*3055552222
NM1*40*2*XYZ REPRICER*****46*66783JJT
HL*1**20*1
NM1*85*1*KILDARE*BEN****XX*1234567893
N3*1234 SEAWAY ST
N4*MIAMI*FL*33111
REF*EI*123456789
PER*IC*CONNIE*TE*3055551234
NM1*87*2
N3*2345 OCEAN BLVD
N4*MIAMI*FL*33111
HL*2*1*22*1
SBR*P********CI
NM1*IL*1*SMITH*JANE****MI*111223333
DMG*D8*19430501*F
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666
N3*3333OCEAN ST
N4*SOUTH MIAMI*FL*33000
REF*G2*PBS3334
HL*3*2*23*0
PAT*19
NM1*QC*1*SMITH*TED
N3*236 N MAIN ST
N4*MIAMI*FL*33413
DMG*D8*19730501*M
CLM*26407789*79.04***11:B:1*Y*A*Y*I*P
HI*BK:4779*BF:2724*BF:2780*BF:53081
NM1*82*1*KILDARE*BEN****XX*1234567893
PRV*PE*PXC*204C00000X
REF*G2*KA6663
NM1*77*2*KILDARE ASSOCIATES*****XX*1234567893
N3*2345 OCEAN BLVD
N4*MIAMI*FL*33111
SBR*S*01*******CI
OI***Y*P**Y
NM1*IL*1*SMITH*JACK****MI*T55TY666
N3*236 N MAIN ST
N4*MIAMI*FL*33111
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666
LX*1
SV1*HC:99213*43*UN*1***1:2:3:4
DTP*472*D8*20051003
LX*2
SV1*HC:90782*15*UN*1***1:2
DTP*472*D8*20051003
LX*3
SV1*HC:J3301*21.04*UN*1***1:2
DTP*472*D8*20051003
SE*52*2021
GE*1*123456789
IEA*1*987654321

The generated PDF file is as follows.

About Us

Redix International, Inc. is an enterprise software company. Redix develops software and provides services to help organizations convert their proprietary or organization-specific data to standardized data. Among the standardized formats supported are X12, EDIFACT, XML, NSF, UB92, HIPAA, HL7, CDA, Blue-Ribbon, FHIR, NCPDP, and PDF.

PDF

Convert HIPAA 837 Professional to CMS 1500 Form

Mapping Specification

Example

About Us

Archives

Categories