X12 837I institutional claim: format and example

837I structure

The full X12 837I layout from its OpenEDI definition, the same model ediFabric uses to parse, validate and generate it: 59 loops and 273 segment positions, in file order. Loops are shaded and their segments indented; Max use is how many times a segment or loop may repeat.

Segment / loop	Name	Usage	Max use
`ST`	Transaction Set Header	Required	1
`BHT`	Beginning of Hierarchical Transaction	Required	1
Any order	The loops below can appear in any order	Required	1
Loop 1000A	Submitter Name	Required	1
`NM1`	Submitter Name	Required	1
`PER`	Submitter EDI Contact Information	Required	2
Loop 1000B	Receiver Name	Required	1
`NM1`	Receiver Name	Required	1
Loop 2000A	Billing Provider Hierarchical Level	Required	>1
`HL`	Billing Provider Hierarchical Level	Required	1
`PRV`	Billing Provider Specialty Information	Situational	1
`CUR`	Foreign Currency Information	Situational	1
Any order	The loops below can appear in any order	Required	1
Loop 2010AA	Billing Provider Name	Required	1
`NM1`	Billing Provider Name	Required	1
`N3`	Billing Provider Address	Required	1
`N4`	Billing Provider City State ZIP Code	Required	1
`REF`	Billing Provider Tax Identification	Required	1
`PER`	Billing Provider Contact Information	Situational	2
Loop 2010AB	Pay Address Name	Situational	1
`NM1`	Pay Address Name	Required	1
`N3`	Pay to Address ADDRESS	Required	1
`N4`	Pay Address City State ZIP Code	Required	1
Loop 2010AC	Pay to Plan Name	Situational	1
`NM1`	Pay to Plan Name	Required	1
`N3`	Pay to Plan Address	Required	1
`N4`	Pay to Plan City State Zip Code	Required	1
Any order	The loops below can appear in any order	Required	1
`REF`	Pay to Plan Secondary Identification	Situational	1
`REF`	Pay to Tax Identification Number	Required	1
Loop 2000B	Subscriber Hierarchical Level	Required	>1
`HL`	Subscriber Hierarchical Level	Required	1
`SBR`	Subscriber Information	Required	1
Any order	The loops below can appear in any order	Required	1
Loop 2010BA	Subscriber Name	Required	1
`NM1`	Subscriber Name	Required	1
`N3`	Subscriber Address	Situational	1
`N4`	Subscriber City State ZIP Code	Situational	1
`DMG`	Subscriber Demographic Information	Situational	1
Any order	The loops below can appear in any order	Situational	1
`REF`	Subscriber Secondary Identification	Situational	1
`REF`	Propertyand Casualty Claim Number	Situational	1
Loop 2010BB	Payer Name	Required	1
`NM1`	Payer Name	Required	1
`N3`	Payer Address	Situational	1
`N4`	Payer City State ZIP Code	Situational	1
Any order	The loops below can appear in any order	Situational	1
`REF`	Payer Secondary Identification	Situational	3
`REF`	Billing Provider Secondary Identification	Situational	1
Loop 2300	Claim Information	Situational	100
`CLM`	Claim Information	Required	1
Any order	The loops below can appear in any order	Required	1
`DTP`	Discharge Hour	Situational	1
`DTP`	Statement Dates	Required	1
`DTP`	Admission Date Hour	Situational	1
`DTP`	Date Repricer Received Date	Situational	1
`CL1`	Institutional Claim Code	Required	1
`PWK`	Claim Supplemental Information	Situational	10
`CN1`	Contract Information	Situational	1
`AMT`	Patient Estimated Amount Due	Situational	1
Any order	The loops below can appear in any order	Situational	1
`REF`	Service Authorization Exception Code	Situational	1
`REF`	Referral Number	Situational	1
`REF`	Prior Authorization	Situational	1
`REF`	Payer Claim Control Number	Situational	1
`REF`	Repriced Claim Number	Situational	1
`REF`	Adjusted Repriced Claim Number	Situational	1
`REF`	Investigational Device Exemption Number	Situational	5
`REF`	Claim Identifier for Transmission Intermediaries	Situational	1
`REF`	Auto Accident State	Situational	1
`REF`	Medical Record Number	Situational	1
`REF`	Demonstration Project Identifier	Situational	1
`REF`	Peer Review Organization PRO Approval Number	Situational	1
`K3`	File Information	Situational	10
Any order	The loops below can appear in any order	Situational	1
`NTE`	Claim Note	Situational	10
`NTE`	Billing Note	Situational	1
`CRC`	EPSDT Referral	Situational	1
Any order	The loops below can appear in any order	Required	1
`HI`	Principal Diagnosis	Required	1
`HI`	Admitting Diagnosis	Situational	1
`HI`	Patient Reason for Visit	Situational	1
`HI`	External Causeof Injury	Situational	1
`HI`	Diagnosis Related Group DRG Information	Situational	1
`HI`	Other Diagnosis Information	Situational	2
`HI`	Principal Procedure Information	Situational	1
`HI`	Other Procedure Information	Situational	2
`HI`	Occurrence Span Information	Situational	2
`HI`	Occurrence Information	Situational	2
`HI`	Value Information	Situational	2
`HI`	Condition Information	Situational	2
`HI`	Treatment Code Information	Situational	2
`HCP`	Claim Pricing Repricing Information	Situational	1
Any order	The loops below can appear in any order	Situational	1
Loop 2310A	Attending Provider Name	Situational	1
`NM1`	Attending Provider Name	Required	1
`PRV`	Attending Provider Specialty Information	Situational	1
`REF`	Attending Provider Secondary Identification	Situational	4
Loop 2310B	Operating Physician Name	Situational	1
`NM1`	Operating Physician Name	Required	1
`REF`	Operating Physician Secondary Identification	Situational	4
Loop 2310C	Other Operating Physician Name	Situational	1
`NM1`	Other Operating Physician Name	Required	1
`REF`	Other Operating Physician Secondary Identification	Situational	4
Loop 2310D	Rendering Provider Name	Situational	1
`NM1`	Rendering Provider Name	Required	1
`REF`	Rendering Provider Secondary Identification	Situational	4
Loop 2310E	Service Facility Location Name	Situational	1
`NM1`	Service Facility Location Name	Required	1
`N3`	Service Facility Location Address	Required	1
`N4`	Service Facility Location City State ZIP	Required	1
`REF`	Service Facility Secondary Identification	Situational	3
Loop 2310F	Referring Provider Name	Situational	1
`NM1`	Referring Provider Name	Required	1
`REF`	Referring Provider Secondary Identification	Situational	3
Loop 2320	Other Subscriber Information	Situational	10
`SBR`	Other Subscriber Information	Required	1
`CAS`	Claim Level Adjustments	Situational	5
Any order	The loops below can appear in any order	Situational	1
`AMT`	Coordinationof Benefits COB Payer Paid Amount	Situational	1
`AMT`	Remaining Patient Liability	Situational	1
`AMT`	Coordinationof Benefits COB Total Non Amount	Situational	1
`OI`	Other Insurance Coverage Information	Required	1
`MIA`	Inpatient Adjudication Information	Situational	1
`MOA`	Outpatient Adjudication Information	Situational	1
Any order	The loops below can appear in any order	Required	1
Loop 2330A	Other Subscriber Name	Required	1
`NM1`	Other Subscriber Name	Required	1
`N3`	Other Subscriber Address	Situational	1
`N4`	Other Subscriber City State ZIP Code	Situational	1
`REF`	Other Subscriber Secondary Information	Situational	2
Loop 2330B	Other Payer Name	Required	1
`NM1`	Other Payer Name	Required	1
`N3`	Other Payer Address	Situational	1
`N4`	Other Payer City State ZIP Code	Situational	1
`DTP`	Claim Check or Remittance Date	Situational	1
Any order	The loops below can appear in any order	Situational	1
`REF`	Other Payer Secondary Identifier	Situational	2
`REF`	Other Payer Prior Authorization Number	Situational	1
`REF`	Other Payer Referral Number	Situational	1
`REF`	Other Payer Claim Adjustment Indicator	Situational	1
`REF`	Other Payer Claim Control Number	Situational	1
Loop 2330C	Other Payer Attending Provider	Situational	1
`NM1`	Other Payer Attending Provider	Required	1
`REF`	Other Payer Attending Provider Secondary Identification	Required	4
Loop 2330D	Other Payer Operating Physician	Situational	1
`NM1`	Other Payer Operating Physician	Required	1
`REF`	Other Payer Operating Physician Secondary Identification	Required	4
Loop 2330E	Other Payer Other Operating Physician	Situational	1
`NM1`	Other Payer Other Operating Physician	Required	1
`REF`	Other Payer Other Operating Physician Secondary Identification	Required	4
Loop 2330F	Other Payer Service Facility Location	Situational	1
`NM1`	Other Payer Service Facility Location	Required	1
`REF`	Other Payer Service Facility Location Secondary Identification	Required	3
Loop 2330G	Other Payer Rendering Provider Name	Situational	1
`NM1`	Other Payer Rendering Provider Name	Required	1
`REF`	Other Payer Rendering Provider Secondary Identifier	Required	4
Loop 2330H	Other Payer Referring Provider	Situational	1
`NM1`	Other Payer Referring Provider	Required	1
`REF`	Other Payer Referring Provider Secondary Identification	Required	3
Loop 2330I	Other Payer Billing Provider	Situational	1
`NM1`	Other Payer Billing Provider	Required	1
`REF`	Other Payer Billing Provider Secondary Identifier	Required	2
Loop 2400	Service Line Number	Required	999
`LX`	Service Line Number	Required	1
`SV2`	Institutional Service Line	Required	1
`PWK`	Line Supplemental Information	Situational	10
`DTP`	Date Service Date	Situational	1
Any order	The loops below can appear in any order	Situational	1
`REF`	Line Item Control Number	Situational	1
`REF`	Repriced Line Item Reference Number	Situational	1
`REF`	Adjusted Repriced Line Item Reference Number	Situational	1
Any order	The loops below can appear in any order	Situational	1
`AMT`	Service Tax Amount	Situational	1
`AMT`	Facility Tax Amount	Situational	1
`NTE`	Third Party Organization Notes	Situational	1
`HCP`	Line Pricing Repricing Information	Situational	1
Loop 2410	Drug Identification	Situational	1
`LIN`	Drug Identification	Required	1
`CTP`	Drug Quantity	Required	1
`REF`	Prescriptionor Compound Drug Association Number	Situational	1
Any order	The loops below can appear in any order	Situational	1
Loop 2420A	Operating Physician Name	Situational	1
`NM1`	Operating Physician Name	Required	1
`REF`	Operating Physician Secondary Identification	Situational	20
Loop 2420B	Other Operating Physician Name	Situational	1
`NM1`	Other Operating Physician Name	Required	1
`REF`	Other Operating Physician Secondary Identification	Situational	20
Loop 2420C	Rendering Provider Name	Situational	1
`NM1`	Rendering Provider Name	Required	1
`REF`	Rendering Provider Secondary Identification	Situational	20
Loop 2420D	Referring Provider Name	Situational	1
`NM1`	Referring Provider Name	Required	1
`REF`	Referring Provider Secondary Identification	Situational	20
Loop 2430	Line Adjudication Information	Situational	15
`SVD`	Line Adjudication Information	Required	1
`CAS`	Line Adjustment	Situational	5
`DTP`	Line Checkor Remittance Date	Required	1
`AMT`	Remaining Patient Liability	Situational	1
Loop 2000C	Patient Hierarchical Level	Situational	>1
`HL`	Patient Hierarchical Level	Required	1
`PAT`	Patient Information	Required	1
Loop 2010CA	Patient Name	Required	1
`NM1`	Patient Name	Required	1
`N3`	Patient Address	Required	1
`N4`	Patient City State ZIP Code	Required	1
`DMG`	Patient Demographic Information	Required	1
Any order	The loops below can appear in any order	Situational	1
`REF`	Propertyand Casualty Claim Number	Situational	1
`REF`	Propertyand Casualty Patient Identifier	Situational	1
Loop 2300	Claim Information	Required	100
`CLM`	Claim Information	Required	1
Any order	The loops below can appear in any order	Required	1
`DTP`	Discharge Hour	Situational	1
`DTP`	Statement Dates	Required	1
`DTP`	Admission Date Hour	Situational	1
`DTP`	Date Repricer Received Date	Situational	1
`CL1`	Institutional Claim Code	Required	1
`PWK`	Claim Supplemental Information	Situational	10
`CN1`	Contract Information	Situational	1
`AMT`	Patient Estimated Amount Due	Situational	1
Any order	The loops below can appear in any order	Situational	1
`REF`	Service Authorization Exception Code	Situational	1
`REF`	Referral Number	Situational	1
`REF`	Prior Authorization	Situational	1
`REF`	Payer Claim Control Number	Situational	1
`REF`	Repriced Claim Number	Situational	1
`REF`	Adjusted Repriced Claim Number	Situational	1
`REF`	Investigational Device Exemption Number	Situational	5
`REF`	Claim Identifier for Transmission Intermediaries	Situational	1
`REF`	Auto Accident State	Situational	1
`REF`	Medical Record Number	Situational	1
`REF`	Demonstration Project Identifier	Situational	1
`REF`	Peer Review Organization PRO Approval Number	Situational	1
`K3`	File Information	Situational	10
Any order	The loops below can appear in any order	Situational	1
`NTE`	Claim Note	Situational	10
`NTE`	Billing Note	Situational	1
`CRC`	EPSDT Referral	Situational	1
Any order	The loops below can appear in any order	Required	1
`HI`	Principal Diagnosis	Required	1
`HI`	Admitting Diagnosis	Situational	1
`HI`	Patient Reason for Visit	Situational	1
`HI`	External Causeof Injury	Situational	1
`HI`	Diagnosis Related Group DRG Information	Situational	1
`HI`	Other Diagnosis Information	Situational	2
`HI`	Principal Procedure Information	Situational	1
`HI`	Other Procedure Information	Situational	2
`HI`	Occurrence Span Information	Situational	2
`HI`	Occurrence Information	Situational	2
`HI`	Value Information	Situational	2
`HI`	Condition Information	Situational	2
`HI`	Treatment Code Information	Situational	2
`HCP`	Claim Pricing Repricing Information	Situational	1
Any order	The loops below can appear in any order	Situational	1
Loop 2310A	Attending Provider Name	Situational	1
`NM1`	Attending Provider Name	Required	1
`PRV`	Attending Provider Specialty Information	Situational	1
`REF`	Attending Provider Secondary Identification	Situational	4
Loop 2310B	Operating Physician Name	Situational	1
`NM1`	Operating Physician Name	Required	1
`REF`	Operating Physician Secondary Identification	Situational	4
Loop 2310C	Other Operating Physician Name	Situational	1
`NM1`	Other Operating Physician Name	Required	1
`REF`	Other Operating Physician Secondary Identification	Situational	4
Loop 2310D	Rendering Provider Name	Situational	1
`NM1`	Rendering Provider Name	Required	1
`REF`	Rendering Provider Secondary Identification	Situational	4
Loop 2310E	Service Facility Location Name	Situational	1
`NM1`	Service Facility Location Name	Required	1
`N3`	Service Facility Location Address	Required	1
`N4`	Service Facility Location City State ZIP	Required	1
`REF`	Service Facility Secondary Identification	Situational	3
Loop 2310F	Referring Provider Name	Situational	1
`NM1`	Referring Provider Name	Required	1
`REF`	Referring Provider Secondary Identification	Situational	3
Loop 2320	Other Subscriber Information	Situational	10
`SBR`	Other Subscriber Information	Required	1
`CAS`	Claim Level Adjustments	Situational	5
Any order	The loops below can appear in any order	Situational	1
`AMT`	Coordinationof Benefits COB Payer Paid Amount	Situational	1
`AMT`	Remaining Patient Liability	Situational	1
`AMT`	Coordinationof Benefits COB Total Non Amount	Situational	1
`OI`	Other Insurance Coverage Information	Required	1
`MIA`	Inpatient Adjudication Information	Situational	1
`MOA`	Outpatient Adjudication Information	Situational	1
Any order	The loops below can appear in any order	Required	1
Loop 2330A	Other Subscriber Name	Required	1
`NM1`	Other Subscriber Name	Required	1
`N3`	Other Subscriber Address	Situational	1
`N4`	Other Subscriber City State ZIP Code	Situational	1
`REF`	Other Subscriber Secondary Information	Situational	2
Loop 2330B	Other Payer Name	Required	1
`NM1`	Other Payer Name	Required	1
`N3`	Other Payer Address	Situational	1
`N4`	Other Payer City State ZIP Code	Situational	1
`DTP`	Claim Check or Remittance Date	Situational	1
Any order	The loops below can appear in any order	Situational	1
`REF`	Other Payer Secondary Identifier	Situational	2
`REF`	Other Payer Prior Authorization Number	Situational	1
`REF`	Other Payer Referral Number	Situational	1
`REF`	Other Payer Claim Adjustment Indicator	Situational	1
`REF`	Other Payer Claim Control Number	Situational	1
Loop 2330C	Other Payer Attending Provider	Situational	1
`NM1`	Other Payer Attending Provider	Required	1
`REF`	Other Payer Attending Provider Secondary Identification	Required	4
Loop 2330D	Other Payer Operating Physician	Situational	1
`NM1`	Other Payer Operating Physician	Required	1
`REF`	Other Payer Operating Physician Secondary Identification	Required	4
Loop 2330E	Other Payer Other Operating Physician	Situational	1
`NM1`	Other Payer Other Operating Physician	Required	1
`REF`	Other Payer Other Operating Physician Secondary Identification	Required	4
Loop 2330F	Other Payer Service Facility Location	Situational	1
`NM1`	Other Payer Service Facility Location	Required	1
`REF`	Other Payer Service Facility Location Secondary Identification	Required	3
Loop 2330G	Other Payer Rendering Provider Name	Situational	1
`NM1`	Other Payer Rendering Provider Name	Required	1
`REF`	Other Payer Rendering Provider Secondary Identifier	Required	4
Loop 2330H	Other Payer Referring Provider	Situational	1
`NM1`	Other Payer Referring Provider	Required	1
`REF`	Other Payer Referring Provider Secondary Identification	Required	3
Loop 2330I	Other Payer Billing Provider	Situational	1
`NM1`	Other Payer Billing Provider	Required	1
`REF`	Other Payer Billing Provider Secondary Identifier	Required	2
Loop 2400	Service Line Number	Required	999
`LX`	Service Line Number	Required	1
`SV2`	Institutional Service Line	Required	1
`PWK`	Line Supplemental Information	Situational	10
`DTP`	Date Service Date	Situational	1
Any order	The loops below can appear in any order	Situational	1
`REF`	Line Item Control Number	Situational	1
`REF`	Repriced Line Item Reference Number	Situational	1
`REF`	Adjusted Repriced Line Item Reference Number	Situational	1
Any order	The loops below can appear in any order	Situational	1
`AMT`	Service Tax Amount	Situational	1
`AMT`	Facility Tax Amount	Situational	1
`NTE`	Third Party Organization Notes	Situational	1
`HCP`	Line Pricing Repricing Information	Situational	1
Loop 2410	Drug Identification	Situational	1
`LIN`	Drug Identification	Required	1
`CTP`	Drug Quantity	Required	1
`REF`	Prescriptionor Compound Drug Association Number	Situational	1
Any order	The loops below can appear in any order	Situational	1
Loop 2420A	Operating Physician Name	Situational	1
`NM1`	Operating Physician Name	Required	1
`REF`	Operating Physician Secondary Identification	Situational	20
Loop 2420B	Other Operating Physician Name	Situational	1
`NM1`	Other Operating Physician Name	Required	1
`REF`	Other Operating Physician Secondary Identification	Situational	20
Loop 2420C	Rendering Provider Name	Situational	1
`NM1`	Rendering Provider Name	Required	1
`REF`	Rendering Provider Secondary Identification	Situational	20
Loop 2420D	Referring Provider Name	Situational	1
`NM1`	Referring Provider Name	Required	1
`REF`	Referring Provider Secondary Identification	Situational	20
Loop 2430	Line Adjudication Information	Situational	15
`SVD`	Line Adjudication Information	Required	1
`CAS`	Line Adjustment	Situational	5
`DTP`	Line Checkor Remittance Date	Required	1
`AMT`	Remaining Patient Liability	Situational	1
`SE`	Transaction Set Trailer	Required	1

Sample 837I file

An inpatient claim with admission details, diagnosis codes and revenue-coded service lines. Paste it into EdiNation to see every element named and validated.

ISA*00*          *00*          *ZZ*1234567        *ZZ*11111          *170508*1141*^*00501*000000101*1*P*:~
GS*HC*XXXXXXX*XXXXX*20170617*1741*101*X*005010X223A2~
ST*837*987654*005010X223A2~
BHT*0019*00*0123*19960918*0932*CH~
NM1*41*2*JONES HOSPITAL*****46*12345~
PER*IC*JANE DOE*TE*9005555555~
NM1*40*2*MEDICARE*****46*00120~
HL*1**20*1~
PRV*BI*PXC*203BA0200N~
NM1*85*2*JONES HOSPITAL*****XX*9876540809~
N3*225 MAIN STREET BARKLEY BUILDING~
N4*CENTERVILLE*PA*17111~
REF*EI*567891234~
PER*IC*CONNIE*TE*3055551234~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*DOE*JOHN*T***MI*030005074A~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
DMG*D8*19261111*M~
NM1*PR*2*MEDICARE B*****PI*00435~
REF*G2*330127~
CLM*756048Q*89.93**14:A:1*A*Y*Y~
DTP*434*RD8*19960911~
CL1*3**01~
HI*BK:3669~
HI*BF:4019*BF:79431~
HI*BH:A1:D8:19261111*BH:A2:D8:19911101*BH:B1:D8:19261111*BH:B2:D8:19870101~
HI*BE:A2:::15.31~
HI*BG:09~
NM1*71*1*JONES*JOHN*J~
REF*1G*B99937~
SBR*S*01*351630*STATE TEACHERS*****CI~
OI***Y***Y~
NM1*IL*1*DOE*JANE*S***MI*222004433~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
NM1*PR*2*STATE TEACHERS*****PI*1135~
LX*1~
SV2*0305*HC:85025*13.39*UN*1~
DTP*472*D8*19960911~
LX*2~
SV2*0730*HC:93005*76.54*UN*3~
DTP*472*D8*19960911~
SE*43*987654~
GE*1*101~
IEA*1*000000101~

The same 837I as JSON

ediFabric turns every loop, segment and element into a named field. This is the transaction from the sample, in the JSON that ediFabric Native and Cloud return and accept.

{
  "ST": {
    "TransactionSetIdentifierCode_01": "837",
    "TransactionSetControlNumber_02": "987654",
    "ImplementationConventionPreference_03": "005010X223A2"
  },
  "BHT_BeginningOfHierarchicalTransaction": {
    "HierarchicalStructureCode_01": "0019",
    "TransactionSetPurposeCode_02": "00",
    "SubmitterTransactionIdentifier_03": "0123",
    "TransactionSetCreationDate_04": "19960918",
    "TransactionSetCreationTime_05": "0932",
    "TransactionTypeCode_06": "CH"
  },
  "AllNM1": {
    "Loop1000A": {
      "NM1_SubmitterName": {
        "EntityIdentifierCode_01": "41",
        "EntityTypeQualifier_02": "2",
        "ResponseContactLastorOrganizationName_03": "JONES HOSPITAL",
        "IdentificationCodeQualifier_08": "46",
        "ResponseContactIdentifier_09": "12345"
      },
      "PER_SubmitterEDIContactInformation": [
        {
          "ContactFunctionCode_01": "IC",
          "ResponseContactName_02": "JANE DOE",
          "CommunicationNumberQualifier_03": "TE",
          "ResponseContactCommunicationNumber_04": "9005555555"
        }
      ]
    },
    "Loop1000B": {
      "NM1_ReceiverName": {
        "EntityIdentifierCode_01": "40",
        "EntityTypeQualifier_02": "2",
        "ResponseContactLastorOrganizationName_03": "MEDICARE",
        "IdentificationCodeQualifier_08": "46",
        "ResponseContactIdentifier_09": "00120"
      }
    }
  },
  "Loop2000A": [
    {
      "HL_BillingProviderHierarchicalLevel": {
        "HierarchicalIDNumber_01": "1",
        "HierarchicalLevelCode_03": "20",
        "HierarchicalChildCode_04": "1"
      },
      "PRV_BillingProviderSpecialtyInformation": {
        "ProviderCode_01": "BI",
        "ReferenceIdentificationQualifier_02": "PXC",
        "ProviderTaxonomyCode_03": "203BA0200N"
      },
      "AllNM1": {
        "Loop2010AA": {
          "NM1_BillingProviderName": {
            "EntityIdentifierCode_01": "85",
            "EntityTypeQualifier_02": "2",
            "ResponseContactLastorOrganizationName_03": "JONES HOSPITAL",
            "IdentificationCodeQualifier_08": "XX",
            "ResponseContactIdentifier_09": "9876540809"
          },
          "N3_BillingProviderAddress": {
            "ResponseContactAddressLine_01": "225 MAIN STREET BARKLEY BUILDING"
          },
          "N4_BillingProviderCity_State_ZIPCode": {
            "AdditionalPatientInformationContactCityName_01": "CENTERVILLE",
            "AdditionalPatientInformationContactStateCode_02": "PA",
            "AdditionalPatientInformationContactPostalZoneorZIPCode_03": "17111"
          },
          "REF_BillingProviderTaxIdentification": {
            "ReferenceIdentificationQualifier_01": "EI",
            "MemberGrouporPolicyNumber_02": "567891234"
          },
          "PER_BillingProviderContactInformation": [
            {
              "ContactFunctionCode_01": "IC",
              "ResponseContactName_02": "CONNIE",
              "CommunicationNumberQualifier_03": "TE",
              "ResponseContactCommunicationNumber_04": "3055551234"
            }
          ]
        }
      },
      "Loop2000B": [
        {
          "HL_SubscriberHierarchicalLevel": {
            "HierarchicalIDNumber_01": "2",
            "HierarchicalParentIDNumber_02": "1",
            "HierarchicalLevelCode_03": "22",
            "HierarchicalChildCode_04": "0"
          },
          "SBR_SubscriberInformation": {
            "PayerResponsibilitySequenceNumberCode_01": "P",
            "IndividualRelationshipCode_02": "18",
            "ClaimFilingIndicatorCode_09": "MB"
          },
          "AllNM1": {
            "Loop2010BA": {
              "NM1_SubscriberName": {
                "EntityIdentifierCode_01": "IL",
                "EntityTypeQualifier_02": "1",
                "ResponseContactLastorOrganizationName_03": "DOE",
                "ResponseContactFirstName_04": "JOHN",
                "ResponseContactMiddleName_05": "T",
                "IdentificationCodeQualifier_08": "MI",
                "ResponseContactIdentifier_09": "030005074A"
              },
              "N3_SubscriberAddress": {
                "ResponseContactAddressLine_01": "125 CITY AVENUE"
              },
              "N4_SubscriberCity_State_ZIPCode": {
                "AdditionalPatientInformationContactCityName_01": "CENTERVILLE",
                "AdditionalPatientInformationContactStateCode_02": "PA",
                "AdditionalPatientInformationContactPostalZoneorZIPCode_03": "17111"
              },
              "DMG_SubscriberDemographicInformation": {
                "DateTimePeriodFormatQualifier_01": "D8",
                "DependentBirthDate_02": "19261111",
                "DependentGenderCode_03": "M"
              }
            },
            "Loop2010BB": {
              "NM1_PayerName": {
                "EntityIdentifierCode_01": "PR",
                "EntityTypeQualifier_02": "2",
                "ResponseContactLastorOrganizationName_03": "MEDICARE B",
                "IdentificationCodeQualifier_08": "PI",
                "ResponseContactIdentifier_09": "00435"
              },
              "AllREF": {
                "REF_BillingProviderSecondaryIdentification": {
                  "ReferenceIdentificationQualifier_01": "G2",
                  "MemberGrouporPolicyNumber_02": "330127"
                }
              }
            }
          },
          "Loop2300": [
            {
              "CLM_ClaimInformation": {
                "PatientControlNumber_01": "756048Q",
                "TotalClaimChargeAmount_02": "89.93",
                "NonInstitutionalClaimTypeCode_04": "14:A:1",
                "HealthCareServiceLocationInformation_05": {
                  "FacilityTypeCode_01": "A"
                },
                "ProviderorSupplierSignatureIndicator_06": "Y",
                "AssignmentorPlanParticipationCode_07": "Y"
              },
              "AllDTP": {
                "DTP_StatementDates": {
                  "DateTimeQualifier_01": "434",
                  "DateTimePeriodFormatQualifier_02": "RD8",
                  "DateTimePeriod_03": "19960911"
                }
              },
              "CL1_InstitutionalClaimCode": {
                "AdmissionTypeCode_01": "3",
                "PatientStatusCode_03": "01"
              },
              "AllHI": {
                "HI_PrincipalDiagnosis": {
                  "HealthCareCodeInformation_01": {
                    "CodeListQualifierCode_01": "BK",
                    "IndustryCode_02": "3669"
                  }
                },
                "HI_OtherDiagnosisInformation": [
                  {
                    "HealthCareCodeInformation_01": {
                      "CodeListQualifierCode_01": "BF",
                      "IndustryCode_02": "4019"
                    },
                    "HealthCareCodeInformation_02": {
                      "CodeListQualifierCode_01": "BF",
                      "IndustryCode_02": "79431"
                    }
                  }
                ],
                "HI_OccurrenceInformation": [
                  {
                    "HealthCareCodeInformation_01": {
                      "CodeListQualifierCode_01": "BH",
                      "IndustryCode_02": "A1",
                      "DateTimePeriodFormatQualifier_03": "D8",
                      "DateTimePeriod_04": "19261111"
                    },
                    "HealthCareCodeInformation_02": {
                      "CodeListQualifierCode_01": "BH",
                      "IndustryCode_02": "A2",
                      "DateTimePeriodFormatQualifier_03": "D8",
                      "DateTimePeriod_04": "19911101"
                    },
                    "HealthCareCodeInformation_03": {
                      "CodeListQualifierCode_01": "BH",
                      "IndustryCode_02": "B1",
                      "DateTimePeriodFormatQualifier_03": "D8",
                      "DateTimePeriod_04": "19261111"
                    },
                    "HealthCareCodeInformation_04": {
                      "CodeListQualifierCode_01": "BH",
                      "IndustryCode_02": "B2",
                      "DateTimePeriodFormatQualifier_03": "D8",
                      "DateTimePeriod_04": "19870101"
                    }
                  }
                ],
                "HI_ValueInformation": [
                  {
                    "HealthCareCodeInformation_01": {
                      "CodeListQualifierCode_01": "BE",
                      "IndustryCode_02": "A2",
                      "MonetaryAmount_05": "15.31"
                    }
                  }
                ],
                "HI_ConditionInformation": [
                  {
                    "HealthCareCodeInformation_01": {
                      "CodeListQualifierCode_01": "BG",
                      "IndustryCode_02": "09"
                    }
                  }
                ]
              },
              "AllNM1": {
                "Loop2310A": {
                  "NM1_AttendingProviderName": {
                    "EntityIdentifierCode_01": "71",
                    "EntityTypeQualifier_02": "1",
                    "ResponseContactLastorOrganizationName_03": "JONES",
                    "ResponseContactFirstName_04": "JOHN",
                    "ResponseContactMiddleName_05": "J"
                  },
                  "REF_AttendingProviderSecondaryIdentification": [
                    {
                      "ReferenceIdentificationQualifier_01": "1G",
                      "MemberGrouporPolicyNumber_02": "B99937"
                    }
                  ]
                }
              },
              "Loop2320": [
                {
                  "SBR_OtherSubscriberInformation": {
                    "PayerResponsibilitySequenceNumberCode_01": "S",
                    "IndividualRelationshipCode_02": "01",
                    "InsuredGrouporPolicyNumber_03": "351630",
                    "OtherInsuredGroupName_04": "STATE TEACHERS",
                    "ClaimFilingIndicatorCode_09": "CI"
                  },
                  "OI_OtherInsuranceCoverageInformation": {
                    "BenefitsAssignmentCertificationIndicator_03": "Y",
                    "ReleaseofInformationCode_06": "Y"
                  },
                  "AllNM1": {
                    "Loop2330A": {
                      "NM1_OtherSubscriberName": {
                        "EntityIdentifierCode_01": "IL",
                        "EntityTypeQualifier_02": "1",
                        "ResponseContactLastorOrganizationName_03": "DOE",
                        "ResponseContactFirstName_04": "JANE",
                        "ResponseContactMiddleName_05": "S",
                        "IdentificationCodeQualifier_08": "MI",
                        "ResponseContactIdentifier_09": "222004433"
                      },
                      "N3_OtherSubscriberAddress": {
                        "ResponseContactAddressLine_01": "125 CITY AVENUE"
                      },
                      "N4_OtherSubscriberCity_State_ZIPCode": {
                        "AdditionalPatientInformationContactCityName_01": "CENTERVILLE",
                        "AdditionalPatientInformationContactStateCode_02": "PA",
                        "AdditionalPatientInformationContactPostalZoneorZIPCode_03": "17111"
                      }
                    },
                    "Loop2330B": {
                      "NM1_OtherPayerName": {
                        "EntityIdentifierCode_01": "PR",
                        "EntityTypeQualifier_02": "2",
                        "ResponseContactLastorOrganizationName_03": "STATE TEACHERS",
                        "IdentificationCodeQualifier_08": "PI",
                        "ResponseContactIdentifier_09": "1135"
                      }
                    }
                  }
                }
              ],
              "Loop2400": [
                {
                  "LX_ServiceLineNumber": {
                    "AssignedNumber_01": "1"
                  },
                  "SV2_InstitutionalServiceLine": {
                    "ServiceLineRevenueCode_01": "0305",
                    "CompositeMedicalProcedureIdentifier_02": {
                      "ProductorServiceIDQualifier_01": "HC",
                      "ProcedureCode_02": "85025"
                    },
                    "LineItemChargeAmount_03": "13.39",
                    "UnitorBasisforMeasurementCode_04": "UN",
                    "ServiceUnitCount_05": "1"
                  },
                  "DTP_Date_ServiceDate": {
                    "DateTimeQualifier_01": "472",
                    "DateTimePeriodFormatQualifier_02": "D8",
                    "DateTimePeriod_03": "19960911"
                  }
                },
                {
                  "LX_ServiceLineNumber": {
                    "AssignedNumber_01": "2"
                  },
                  "SV2_InstitutionalServiceLine": {
                    "ServiceLineRevenueCode_01": "0730",
                    "CompositeMedicalProcedureIdentifier_02": {
                      "ProductorServiceIDQualifier_01": "HC",
                      "ProcedureCode_02": "93005"
                    },
                    "LineItemChargeAmount_03": "76.54",
                    "UnitorBasisforMeasurementCode_04": "UN",
                    "ServiceUnitCount_05": "3"
                  },
                  "DTP_Date_ServiceDate": {
                    "DateTimeQualifier_01": "472",
                    "DateTimePeriodFormatQualifier_02": "D8",
                    "DateTimePeriod_03": "19960911"
                  }
                }
              ]
            }
          ]
        }
      ]
    }
  ],
  "SE": {
    "NumberofIncludedSegments_01": "43",
    "TransactionSetControlNumber_02": "987654"
  }
}

Parse and validate an 837I file

Read the file into typed objects with ediFabric .NET, convert it to JSON in process with the ediFabric Native bindings for Python, Java and C, or post it to the ediFabric Cloud REST API from any language.

.NET
Python
Java
C
Cloud

using EdiFabric.Templates.Hipaa5010;

License.SetSerial("YOUR_SERIAL_KEY");

using (var stream = File.OpenRead(@"C:\edi\InstitutionalClaim.txt"))
using (var reader = new X12Reader(stream, "EdiFabric.Templates.Hipaa"))
{
    var items = await reader.ReadToEndAsync();
    foreach (var transaction in items.OfType<TS837I>())
    {
        if (transaction.IsValid(out MessageErrorContext errors))
            Console.WriteLine($"{transaction.ST.TransactionSetControlNumber_02} is valid");
        else
            Console.WriteLine(string.Join(Environment.NewLine, errors.Flatten()));
    }
} Install and get started 837I example project Walkthrough
import json
import edifabric_x12 as ef

serial = "YOUR_SERIAL_KEY"
ef.load_library()
ef.set_serial(serial)
ef.set_map(json.dumps({"default": serial, "maps": {}}))

edi = open("InstitutionalClaim.txt", "rb").read()
output, offset = ef.parse(edi, ef.ParseMode.JSON_VALIDATE)
transactions = output[:offset]
report = json.loads(output[offset:])
print(report["errors_count"]) Python bindingsediFabric Native
import com.edifabric.nativex12.EdiFabricX12;
import com.edifabric.nativex12.ParseMode;
import com.edifabric.nativex12.ParseResult;

String serial = "YOUR_SERIAL_KEY";
EdiFabricX12.loadLibrary();
EdiFabricX12.setSerial(serial);
EdiFabricX12.setMap("{\"default\":\"" + serial + "\",\"maps\":{}}");

String edi = Files.readString(Path.of("InstitutionalClaim.txt"));
ParseResult result = EdiFabricX12.parse(edi, ParseMode.JSON_VALIDATE);
System.out.println(result.getTransactions());
System.out.println(result.getReport()); Java bindingsediFabric Native
#include "edifabric_x12.h"

const char *serial = "YOUR_SERIAL_KEY";
ef_parse_result result;

if (ef_load_library(NULL) != 0)
    return 1;
ef_set_serial(serial);
ef_set_map("{\"default\":\"YOUR_SERIAL_KEY\",\"maps\":{}}");

char *edi = read_file("InstitutionalClaim.txt", NULL);   /* helper in example_all_functions.c */
if (ef_parse(edi, EF_PARSE_JSON_VALIDATE, NULL, &result) == 0) {
    /* transactions = output[0 .. offset), report = output[offset .. length) */
    fwrite(result.output.data, 1, (size_t)result.output.length, stdout);
    ef_free(result.output.data);
} C bindingsediFabric Native
curl -X POST 'https://api.edination.com/v2/x12/read' \
-H 'Ocp-Apim-Subscription-Key: YOUR_SERIAL_KEY' \
-H 'Content-Type: application/octet-stream' \
--data-binary '@InstitutionalClaim.txt' TranslateValidateediFabric Cloud

Generate an 837I file

Populate a TS837I object in .NET, or pass JSON in the shape shown above to ediFabric Native or ediFabric Cloud, and get a valid 837I file back.

.NET
Python
Java
C
Cloud

using EdiFabric.Templates.Hipaa5010;

License.SetSerial("YOUR_SERIAL_KEY");

var transaction = new TS837I();

//  ST TRANSACTION SET HEADER
transaction.ST = new ST();
transaction.ST.TransactionSetIdentifierCode_01 = "837";
transaction.ST.TransactionSetControlNumber_02 = "0001";
transaction.ST.ImplementationConventionPreference_03 = "005010X223A2";

//  BHT BEGINNING OF HIERARCHICAL TRANSACTION
transaction.BHT_BeginningOfHierarchicalTransaction = new BHT_BeginningOfHierarchicalTransaction_8();
transaction.BHT_BeginningOfHierarchicalTransaction.HierarchicalStructureCode_01 = "0019";
transaction.BHT_BeginningOfHierarchicalTransaction.TransactionSetPurposeCode_02 = "00";
transaction.BHT_BeginningOfHierarchicalTransaction.SubmitterTransactionIdentifier_03 = "0123";
transaction.BHT_BeginningOfHierarchicalTransaction.TransactionSetCreationDate_04 = "19960918";
transaction.BHT_BeginningOfHierarchicalTransaction.TransactionSetCreationTime_05 = "0932";
transaction.BHT_BeginningOfHierarchicalTransaction.TransactionTypeCode_06 = "CH";

//  Occurrence of NM1 Loops in any order
transaction.AllNM1 = new All_NM1_837I_6();

//  Begin 1000A Loop SUBMITTER NAME
transaction.AllNM1.Loop1000A = new Loop_1000A_837I();

// ... set the remaining loops and segments the same way

// SegmentBuilders is in the Common project of the example repository
using (var stream = new MemoryStream())
{
    using (var writer = new X12Writer(stream))
    {
        writer.Write(SegmentBuilders.BuildIsa("1"));
        writer.Write(SegmentBuilders.BuildGs("1", "SENDER1", "RECEIVER1", "005010X223A2"));
        writer.Write(transaction);
    }
    Console.WriteLine(Encoding.UTF8.GetString(stream.ToArray()));
} Install and get started Full 837I build methodExample repository
import json
import edifabric_x12 as ef

serial = "YOUR_SERIAL_KEY"
ef.load_library()
ef.set_serial(serial)
ef.set_map(json.dumps({"default": serial, "maps": {}}))

# the transactions JSON returned by ef.parse, edited or produced by your application
transactions = open("InstitutionalClaim.json", "rb").read()
edi = ef.build(transactions, postfix="\r\n")
print(edi) Python bindings
import com.edifabric.nativex12.EdiFabricX12;

String serial = "YOUR_SERIAL_KEY";
EdiFabricX12.loadLibrary();
EdiFabricX12.setSerial(serial);
EdiFabricX12.setMap("{\"default\":\"" + serial + "\",\"maps\":{}}");

// the transactions JSON returned by parse, edited or produced by your application
String transactions = Files.readString(Path.of("InstitutionalClaim.json"));
String edi = EdiFabricX12.build(transactions, "\r\n");
System.out.println(edi); Java bindings
#include "edifabric_x12.h"

ef_buffer edi;

if (ef_load_library(NULL) != 0)
    return 1;
ef_set_serial("YOUR_SERIAL_KEY");
ef_set_map("{\"default\":\"YOUR_SERIAL_KEY\",\"maps\":{}}");

/* the transactions JSON returned by ef_parse, edited or produced by your application */
char *transactions = read_file("InstitutionalClaim.json", NULL);
if (ef_build(transactions, "\r\n", &edi) == 0) {
    fwrite(edi.data, 1, (size_t)edi.length, stdout);
    ef_free(edi.data);
} C bindings
# the JSON returned by /read, edited or produced by your application
curl -X POST 'https://api.edination.com/v2/x12/write' \
-H 'Ocp-Apim-Subscription-Key: YOUR_SERIAL_KEY' \
-H 'Content-Type: application/json' \
--data-binary '@InstitutionalClaim.json' \
-o 'InstitutionalClaim.txt' How-tosediFabric Cloud

Complete ediFabric .NET example

A complete C# program for the X12 837I, built on TS837I in EdiFabric.Templates.Hipaa. The same code is in the ediFabric .NET examples on GitHub.

using EdiFabric.Framework.Readers;
using EdiFabric.Framework.Writers;
using EdiFabric.Templates.Hipaa5010;
using System.Collections.Generic;
using System.IO;
using System.Linq;
using EdiFabric.Core.Model.Edi;
using EdiFabric.Core.Model.Edi.X12;
using EdiFabric.Examples.X12.Common;

namespace EdiFabric.Examples.X12.T837I
{
    class Program
    {
        static void Main(string[] args)
        {
            SerialKey.Set(Common.SerialKey.Get());
            Read();
            Write();
        }

        ///
        /// Read Institutional Claim
        ///
        static void Read()
        {
            var ediStream = File.OpenRead(Directory.GetCurrentDirectory() + @"\..\..\..\Files\Hipaa\InstitutionalClaim.txt");

            List ediItems;
            using (var ediReader = new X12Reader(ediStream, "EdiFabric.Templates.Hipaa"))
                ediItems = ediReader.ReadToEnd().ToList();

            var transactions = ediItems.OfType();

            foreach (var transaction in transactions)
            {
                if (transaction.HasErrors)
                {
                    //  partially parsed
                    var errors = transaction.ErrorContext.Flatten();
                }
            }
        }

        ///
        /// Write Institutional Claim
        ///
        static void Write()
        {
            var transaction = BuildInstitutionalClaim("987654");

            using (var stream = new MemoryStream())
            {
                using (var writer = new X12Writer(stream))
                {
                    writer.Write(SegmentBuilders.BuildIsa("1"));
                    writer.Write(SegmentBuilders.BuildGs("1", "SENDER1", "RECEIVER1", "005010X223A2"));
                    writer.Write(transaction);
                }

                var ediString = stream.LoadToString();
            }
        }

        ///
        /// Build institutional claim.
        /// Original from http://www.x12.org/examples/005010X223/institutional/837-institutional-claim/
        /// The patient is a different person than the subscriber. The payer is a commercial health insurance company.
        /// Scenario:
        /// PRIMARY PAYER SUBSCRIBER: John T Doe
        /// SUBSCRIBER ADDRESS: 125 City Avenue, Centerville, PA 17111
        /// SEX: M
        /// DOB: 11/11/1926
        /// MEDICARE INSURANCE ID#: 030005074A
        /// PAYER ID #: 00435
        /// PATIENT: Same as Primary Subscriber
        /// DESTINATION PAYER: Medicare B
        /// SUBMITTER: Jones Hospital
        /// EDI#: 12345
        /// RECEIVER: Medicare
        /// EDI#: 00120
        /// BILLING PROVIDER: Jones Hospital
        /// NPI: 9876540809
        /// TIN: 567891234
        /// MEDICARE PROVIDER: #330127
        /// ADDRESS: 225 Main Street Barkley Building, Centerville, PA 17111
        /// ATTENDING PHYSICIAN: John J Jones
        /// UPIN #: B99937
        /// PATIENT ACCOUNT NUMBER: 756048Q
        /// DATE OF ADMISSION: 09/11/96
        /// STATEMENT PERIOD DATE: 09/11/96 - 09/11/96
        /// PLACE OF SERVICE: Inpatient Hospital
        /// Occurrence Codes and Dates:
        /// A1 11/11/26
        /// A2 11/01/91
        /// B1 11/11/26
        /// B2 01/01/87
        /// Condition Codes: 09
        /// Value Codes: A2 $15.31
        /// PRINCIPAL DIAGNOSIS CODE: 366.9
        /// SECONDARY DIAGNOSIS CODES:
        /// 401.9
        /// 794.31
        /// NUMBER OF COVERED DAYS: 1
        /// SERVICES:
        /// INSTITUTIONAL SERVICES RENDERED:
        /// REVENUE CODE: 0305 HCPCS Procedure Code: 85025 Unit: 1 Price $13.39
        /// REVENUE CODE: 0730 HCPCS Procedure Code: 93005 Unit: 1 Price: $76.54
        /// TOTAL CHARGES: $89.93
        /// SECONDARY PAYER SUBSCRIBER: Jane S Doe(wife)
        /// SUBSCRIBER ADDRESS: 125 City Avenue, Centerville, PA 17111
        /// SEX: F
        /// DOB: 12/11/1927
        /// STATE TEACHERS ID#: 222004433
        /// PAYER ID #: 1135
        ///
        static TS837I BuildInstitutionalClaim(string controlNumber)
        {
            var result = new TS837I();

            //  ST TRANSACTION SET HEADER
            result.ST = new ST();
            result.ST.TransactionSetIdentifierCode_01 = "837";
            result.ST.TransactionSetControlNumber_02 = controlNumber.PadLeft(9, '0');
            result.ST.ImplementationConventionPreference_03 = "005010X223A2";

            //  BHT BEGINNING OF HIERARCHICAL TRANSACTION
            result.BHT_BeginningOfHierarchicalTransaction = new BHT_BeginningOfHierarchicalTransaction_8();
            result.BHT_BeginningOfHierarchicalTransaction.HierarchicalStructureCode_01 = "0019";
            result.BHT_BeginningOfHierarchicalTransaction.TransactionSetPurposeCode_02 = "00";
            result.BHT_BeginningOfHierarchicalTransaction.SubmitterTransactionIdentifier_03 = "0123";
            result.BHT_BeginningOfHierarchicalTransaction.TransactionSetCreationDate_04 = "19960918";
            result.BHT_BeginningOfHierarchicalTransaction.TransactionSetCreationTime_05 = "0932";
            result.BHT_BeginningOfHierarchicalTransaction.TransactionTypeCode_06 = "CH";

            //  Occurrence of NM1 Loops in any order
            result.AllNM1 = new All_NM1_837I_6();

            //  Begin 1000A Loop SUBMITTER NAME
            result.AllNM1.Loop1000A = new Loop_1000A_837I();

            //  NM1 SUBMITTER NAME
            result.AllNM1.Loop1000A.NM1_SubmitterName = new NM1_InformationReceiverName_4();
            result.AllNM1.Loop1000A.NM1_SubmitterName.EntityIdentifierCode_01 = "41";
            result.AllNM1.Loop1000A.NM1_SubmitterName.EntityTypeQualifier_02 = "2";
            result.AllNM1.Loop1000A.NM1_SubmitterName.ResponseContactLastorOrganizationName_03 = "JONES HOSPITAL";
            result.AllNM1.Loop1000A.NM1_SubmitterName.IdentificationCodeQualifier_08 = "46";
            result.AllNM1.Loop1000A.NM1_SubmitterName.ResponseContactIdentifier_09 = "12345";

            //  Repeating PER Patient information
            result.AllNM1.Loop1000A.PER_SubmitterEDIContactInformation = new List();

            //  PER SUBMITTER EDI CONTACT INFORMATION
            var per1 = new PER_BillingProviderContactInformation();
            per1.ContactFunctionCode_01 = "IC";
            per1.ResponseContactName_02 = "JANE DOE";
            per1.CommunicationNumberQualifier_03 = "TE";
            per1.ResponseContactCommunicationNumber_04 = "9005555555";
            result.AllNM1.Loop1000A.PER_SubmitterEDIContactInformation.Add(per1);

            //  End 1000A Loop

            //  Begin 1000B Loop RECEIVER NAME
            result.AllNM1.Loop1000B = new Loop_1000B_837I();

            //  NM1 RECEIVER NAME
            result.AllNM1.Loop1000B.NM1_ReceiverName = new NM1_ReceiverName();
            result.AllNM1.Loop1000B.NM1_ReceiverName.EntityIdentifierCode_01 = "40";
            result.AllNM1.Loop1000B.NM1_ReceiverName.EntityTypeQualifier_02 = "2";
            result.AllNM1.Loop1000B.NM1_ReceiverName.ResponseContactLastorOrganizationName_03 = "MEDICARE";
            result.AllNM1.Loop1000B.NM1_ReceiverName.IdentificationCodeQualifier_08 = "46";
            result.AllNM1.Loop1000B.NM1_ReceiverName.ResponseContactIdentifier_09 = "00120";

            //  End 1000B Loop

            //  Repeating 2000A Loops
            result.Loop2000A = new List();

            //  Begin 2000A Loop BILLING PROVIDER
            var loop2000A = new Loop_2000A_837I();

            //  HL BILLING PROVIDER HIERARCHICAL LEVEL
            loop2000A.HL_BillingProviderHierarchicalLevel = new HL_BillingProviderHierarchicalLevel();
            loop2000A.HL_BillingProviderHierarchicalLevel.HierarchicalIDNumber_01 = "1";
            loop2000A.HL_BillingProviderHierarchicalLevel.HierarchicalLevelCode_03 = "20";
            loop2000A.HL_BillingProviderHierarchicalLevel.HierarchicalChildCode_04 = "1";

            //  PRV BILLING PROVIDER SPECIALTY
            loop2000A.PRV_BillingProviderSpecialtyInformation = new PRV_BillingProviderSpecialtyInformation();
            loop2000A.PRV_BillingProviderSpecialtyInformation.ProviderCode_01 = "BI";
            loop2000A.PRV_BillingProviderSpecialtyInformation.ReferenceIdentificationQualifier_02 = "PXC";
            loop2000A.PRV_BillingProviderSpecialtyInformation.ProviderTaxonomyCode_03 = "203BA0200N";

            //  Occurrence of NM1 Loops in any order
            loop2000A.AllNM1 = new All_NM1_837I();

            //  Begin 2010AA Loop BILLING PROVIDER NAME
            loop2000A.AllNM1.Loop2010AA = new Loop_2010AA_837I();

            //  NM1 BILLING PROVIDER NAME INCLUDING NATIONAL PROVIDER ID
            loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName = new NM1_BillingProviderName_3();
            loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.EntityIdentifierCode_01 = "85";
            loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.EntityTypeQualifier_02 = "2";
            loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.ResponseContactLastorOrganizationName_03 = "JONES HOSPITAL";
            loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.IdentificationCodeQualifier_08 = "XX";
            loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.ResponseContactIdentifier_09 = "9876540809";

            //  N3 BILLING PROVIDER ADDRESS
            loop2000A.AllNM1.Loop2010AA.N3_BillingProviderAddress = new N3_AdditionalPatientInformationContactAddress();
            loop2000A.AllNM1.Loop2010AA.N3_BillingProviderAddress.ResponseContactAddressLine_01 = "225 MAIN STREET BARKLEY BUILDING";

            //  N4 BILLING PROVIDER LOCATION
            loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode = new N4_AdditionalPatientInformationContactCity();
            loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode.AdditionalPatientInformationContactCityName_01 = "CENTERVILLE";
            loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode.AdditionalPatientInformationContactStateCode_02 = "PA";
            loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode.AdditionalPatientInformationContactPostalZoneorZIPCode_03 = "17111";

            //  REF BILLING PROVIDER TAX IDENTIFICATION NUMBER
            loop2000A.AllNM1.Loop2010AA.REF_BillingProviderTaxIdentification = new REF_BillingProviderTaxIdentification_2();
            loop2000A.AllNM1.Loop2010AA.REF_BillingProviderTaxIdentification.ReferenceIdentificationQualifier_01 = "EI";
            loop2000A.AllNM1.Loop2010AA.REF_BillingProviderTaxIdentification.MemberGrouporPolicyNumber_02 = "567891234";

            //  Repeating PER billing provider contact information
            loop2000A.AllNM1.Loop2010AA.PER_BillingProviderContactInformation = new List();

            //  PER BILLING PROVIDER CONTACT INFORMATION
            var per2 = new PER_BillingProviderContactInformation();
            per2.ContactFunctionCode_01 = "IC";
            per2.ResponseContactName_02 = "CONNIE";
            per2.CommunicationNumberQualifier_03 = "TE";
            per2.ResponseContactCommunicationNumber_04 = "3055551234";
            loop2000A.AllNM1.Loop2010AA.PER_BillingProviderContactInformation.Add(per2);

            //  End 2010AA Loop

            //  Repeating 2000B Loops
            loop2000A.Loop2000B = new List();

            //  Begin 2000B Loop SUBSCRIBER HL LOOP
            var loop2000B = new Loop_2000B_837I();

            //  HL SUBSCRIBER HIERARCHICAL LEVEL
            loop2000B.HL_SubscriberHierarchicalLevel = new HL_SubscriberHierarchicalLevel();
            loop2000B.HL_SubscriberHierarchicalLevel.HierarchicalIDNumber_01 = "2";
            loop2000B.HL_SubscriberHierarchicalLevel.HierarchicalParentIDNumber_02 = "1";
            loop2000B.HL_SubscriberHierarchicalLevel.HierarchicalLevelCode_03 = "22";
            loop2000B.HL_SubscriberHierarchicalLevel.HierarchicalChildCode_04 = "0";

            //  SBR SUBSCRIBER INFORMATION
            loop2000B.SBR_SubscriberInformation = new SBR_SubscriberInformation_2();
            loop2000B.SBR_SubscriberInformation.PayerResponsibilitySequenceNumberCode_01 = "P";
            loop2000B.SBR_SubscriberInformation.IndividualRelationshipCode_02 = "18";
            loop2000B.SBR_SubscriberInformation.ClaimFilingIndicatorCode_09 = "MB";

            //  Occurrence of NM1 Loops in any order
            loop2000B.AllNM1 = new All_NM1_837I_2();

            //  Begin 2010BA Loop SUBSCRIBER NAME LOOP
            loop2000B.AllNM1.Loop2010BA = new Loop_2010BA_837I();

            //  NM1 SUBSCRIBER NAME
            loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName = new NM1_SubscriberName_5();
            loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.EntityIdentifierCode_01 = "IL";
            loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.EntityTypeQualifier_02 = "1";
            loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactLastorOrganizationName_03 = "DOE";
            loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactFirstName_04 = "JOHN";
            loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactMiddleName_05 = "T";
            loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.IdentificationCodeQualifier_08 = "MI";
            loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactIdentifier_09 = "030005074A";

            //  N3 SUBSCRIBER ADDRESS
            loop2000B.AllNM1.Loop2010BA.N3_SubscriberAddress = new N3_AdditionalPatientInformationContactAddress();
            loop2000B.AllNM1.Loop2010BA.N3_SubscriberAddress.ResponseContactAddressLine_01 = "125 CITY AVENUE";

            //  N4 SUBSCRIBER LOCATION
            loop2000B.AllNM1.Loop2010BA.N4_SubscriberCity_State_ZIPCode = new N4_AdditionalPatientInformationContactCity();
            loop2000B.AllNM1.Loop2010BA.N4_SubscriberCity_State_ZIPCode.AdditionalPatientInformationContactCityName_01 = "CENTERVILLE";
            loop2000B.AllNM1.Loop2010BA.N4_SubscriberCity_State_ZIPCode.AdditionalPatientInformationContactStateCode_02 = "PA";
            loop2000B.AllNM1.Loop2010BA.N4_SubscriberCity_State_ZIPCode.AdditionalPatientInformationContactPostalZoneorZIPCode_03 = "17111";

            //  DMG SUBSCRIBER DEMOGRAPHIC INFORMATION
            loop2000B.AllNM1.Loop2010BA.DMG_SubscriberDemographicInformation = new DMG_PatientDemographicInformation();
            loop2000B.AllNM1.Loop2010BA.DMG_SubscriberDemographicInformation.DateTimePeriodFormatQualifier_01 = "D8";
            loop2000B.AllNM1.Loop2010BA.DMG_SubscriberDemographicInformation.DependentBirthDate_02 = "19261111";
            loop2000B.AllNM1.Loop2010BA.DMG_SubscriberDemographicInformation.DependentGenderCode_03 = "M";

            //  End 2010BA Loop

            //  Begin 2010BB Loop PAYER NAME LOOP
            loop2000B.AllNM1.Loop2010BB = new Loop_2010BB_837I();

            //  NM1 PAYER NAME
            loop2000B.AllNM1.Loop2010BB.NM1_PayerName = new NM1_OtherPayerName();
            loop2000B.AllNM1.Loop2010BB.NM1_PayerName.EntityIdentifierCode_01 = "PR";
            loop2000B.AllNM1.Loop2010BB.NM1_PayerName.EntityTypeQualifier_02 = "2";
            loop2000B.AllNM1.Loop2010BB.NM1_PayerName.ResponseContactLastorOrganizationName_03 = "MEDICARE B";
            loop2000B.AllNM1.Loop2010BB.NM1_PayerName.IdentificationCodeQualifier_08 = "PI";
            loop2000B.AllNM1.Loop2010BB.NM1_PayerName.ResponseContactIdentifier_09 = "00435";

            //  Occurrence of REF Segments in any order
            loop2000B.AllNM1.Loop2010BB.AllREF = new All_REF_837I_3();

            //  REF BILLING PROVIDER SECONDARY IDENTIFICATION
            loop2000B.AllNM1.Loop2010BB.AllREF.REF_BillingProviderSecondaryIdentification = new REF_BillingProviderSecondaryIdentification();
            loop2000B.AllNM1.Loop2010BB.AllREF.REF_BillingProviderSecondaryIdentification.ReferenceIdentificationQualifier_01 = "G2";
            loop2000B.AllNM1.Loop2010BB.AllREF.REF_BillingProviderSecondaryIdentification.MemberGrouporPolicyNumber_02 = "330127";

            //  End 2010BB Loop

            //  Repeating 2300 Loops
            loop2000B.Loop2300 = new List();

            //  Begin 2300 Loop CLAIM INFORMATION
            var loop2300 = new Loop_2300_837I();

            //  CLM CLAIM LEVEL INFORMATION
            loop2300.CLM_ClaimInformation = new CLM_ClaimInformation_2();
            loop2300.CLM_ClaimInformation.PatientControlNumber_01 = "756048Q";
            loop2300.CLM_ClaimInformation.TotalClaimChargeAmount_02 = "89.93";
            loop2300.CLM_ClaimInformation.NonInstitutionalClaimTypeCode_04 = "14:A:1";
            loop2300.CLM_ClaimInformation.HealthCareServiceLocationInformation_05 = new C023_HealthCareServiceLocationInformation_3();
            loop2300.CLM_ClaimInformation.HealthCareServiceLocationInformation_05.FacilityTypeCode_01 = "A";
            loop2300.CLM_ClaimInformation.ProviderorSupplierSignatureIndicator_06 = "Y";
            loop2300.CLM_ClaimInformation.AssignmentorPlanParticipationCode_07 = "Y";

            //  Occurrence of DTP Segments in any order
            loop2300.AllDTP = new All_DTP_837I();

            //  DTP STATEMENT DATES
            loop2300.AllDTP.DTP_StatementDates = new DTP_StatementDates();
            loop2300.AllDTP.DTP_StatementDates.DateTimeQualifier_01 = "434";
            loop2300.AllDTP.DTP_StatementDates.DateTimePeriodFormatQualifier_02 = "RD8";
            loop2300.AllDTP.DTP_StatementDates.DateTimePeriod_03 = "19960911";

            //  CL1 INSTITUTIONAL CLAIM CODE
            loop2300.CL1_InstitutionalClaimCode = new CL1_InstitutionalClaimCode();
            loop2300.CL1_InstitutionalClaimCode.AdmissionTypeCode_01 = "3";
            loop2300.CL1_InstitutionalClaimCode.PatientStatusCode_03 = "01";

            //  Occurrence of HI Segments in any order
            loop2300.AllHI = new All_HI_837I();

            //  HI PRINCIPAL DIAGNOSIS CODES
            loop2300.AllHI.HI_PrincipalDiagnosis = new HI_PrincipalDiagnosis();
            loop2300.AllHI.HI_PrincipalDiagnosis.HealthCareCodeInformation_01 = new C022_HealthCareCodeInformation_8();
            loop2300.AllHI.HI_PrincipalDiagnosis.HealthCareCodeInformation_01.CodeListQualifierCode_01 = "BK";
            loop2300.AllHI.HI_PrincipalDiagnosis.HealthCareCodeInformation_01.IndustryCode_02 = "3669";

            //  Repeatable HI Other Diagnostics
            loop2300.AllHI.HI_OtherDiagnosisInformation = new List();

            //  HI OTHER DIAGNOSIS INFORMATION
            var hi1 = new HI_OtherDiagnosisInformation();
            hi1.HealthCareCodeInformation_01 = new C022_HealthCareCodeInformation_4();
            hi1.HealthCareCodeInformation_01.CodeListQualifierCode_01 = "BF";
            hi1.HealthCareCodeInformation_01.IndustryCode_02 = "4019";
            hi1.HealthCareCodeInformation_02 = new C022_HealthCareCodeInformation_4();
            hi1.HealthCareCodeInformation_02.CodeListQualifierCode_01 = "BF";
            hi1.HealthCareCodeInformation_02.IndustryCode_02 = "79431";
            loop2300.AllHI.HI_OtherDiagnosisInformation.Add(hi1);

            //  Repeatable HI Occurrence Information
            loop2300.AllHI.HI_OccurrenceInformation = new List();

            //  HI OCCURRENCE INFORMATION
            var hi3 = new HI_OccurrenceInformation();
            hi3.HealthCareCodeInformation_01 = new C022_HealthCareCodeInformation_6();
            hi3.HealthCareCodeInformation_01.CodeListQualifierCode_01 = "BH";
            hi3.HealthCareCodeInformation_01.IndustryCode_02 = "A1";
            hi3.HealthCareCodeInformation_01.DateTimePeriodFormatQualifier_03 = "D8";
            hi3.HealthCareCodeInformation_01.DateTimePeriod_04 = "19261111";
            hi3.HealthCareCodeInformation_02 = new C022_HealthCareCodeInformation_6();
            hi3.HealthCareCodeInformation_02.CodeListQualifierCode_01 = "BH";
            hi3.HealthCareCodeInformation_02.IndustryCode_02 = "A2";
            hi3.HealthCareCodeInformation_02.DateTimePeriodFormatQualifier_03 = "D8";
            hi3.HealthCareCodeInformation_02.DateTimePeriod_04 = "19911101";
            hi3.HealthCareCodeInformation_03 = new C022_HealthCareCodeInformation_6();
            hi3.HealthCareCodeInformation_03 = new C022_HealthCareCodeInformation_6();
            hi3.HealthCareCodeInformation_03.CodeListQualifierCode_01 = "BH";
            hi3.HealthCareCodeInformation_03.IndustryCode_02 = "B1";
            hi3.HealthCareCodeInformation_03.DateTimePeriodFormatQualifier_03 = "D8";
            hi3.HealthCareCodeInformation_03.DateTimePeriod_04 = "19261111";
            hi3.HealthCareCodeInformation_04 = new C022_HealthCareCodeInformation_6();
            hi3.HealthCareCodeInformation_04.CodeListQualifierCode_01 = "BH";
            hi3.HealthCareCodeInformation_04.IndustryCode_02 = "B2";
            hi3.HealthCareCodeInformation_04.DateTimePeriodFormatQualifier_03 = "D8";
            hi3.HealthCareCodeInformation_04.DateTimePeriod_04 = "19870101";
            loop2300.AllHI.HI_OccurrenceInformation.Add(hi3);

            //  Repeatable HI Value Information
            loop2300.AllHI.HI_ValueInformation = new List();

            //  HI VALUE INFORMATION
            var hi7 = new HI_ValueInformation();
            hi7.HealthCareCodeInformation_01 = new C022_HealthCareCodeInformation_7();
            hi7.HealthCareCodeInformation_01.CodeListQualifierCode_01 = "BE";
            hi7.HealthCareCodeInformation_01.IndustryCode_02 = "A2";
            hi7.HealthCareCodeInformation_01.MonetaryAmount_05 = "15.31";
            loop2300.AllHI.HI_ValueInformation.Add(hi7);

            //  Repeatable HI Condition Information
            loop2300.AllHI.HI_ConditionInformation = new List();

            //  HI CONDITION INFORMATION
            var hi8 = new HI_ConditionInformation();
            hi8.HealthCareCodeInformation_01 = new C022_HealthCareCodeInformation_13();
            hi8.HealthCareCodeInformation_01.CodeListQualifierCode_01 = "BG";
            hi8.HealthCareCodeInformation_01.IndustryCode_02 = "09";
            loop2300.AllHI.HI_ConditionInformation.Add(hi8);

            //  Occurrence of NM1 Loops in any order
            loop2300.AllNM1 = new All_NM1_837I_3();

            //  Begin 2310A Loop ATTENDING PROVIDER NAME
            loop2300.AllNM1.Loop2310A = new Loop_2310A_837I();

            //  NM1 ATTENDING PROVIDER
            loop2300.AllNM1.Loop2310A.NM1_AttendingProviderName = new NM1_AttendingProviderName();
            loop2300.AllNM1.Loop2310A.NM1_AttendingProviderName.EntityIdentifierCode_01 = "71";
            loop2300.AllNM1.Loop2310A.NM1_AttendingProviderName.EntityTypeQualifier_02 = "1";
            loop2300.AllNM1.Loop2310A.NM1_AttendingProviderName.ResponseContactLastorOrganizationName_03 = "JONES";
            loop2300.AllNM1.Loop2310A.NM1_AttendingProviderName.ResponseContactFirstName_04 = "JOHN";
            loop2300.AllNM1.Loop2310A.NM1_AttendingProviderName.ResponseContactMiddleName_05 = "J";

            //  Repeating REF Secondary Identification
            loop2300.AllNM1.Loop2310A.REF_AttendingProviderSecondaryIdentification = new List();

            //  REF ATTENDING PROVIDER SECONDARY IDENTIFICATION
            var ref1 = new REF_AssistantSurgeonSecondaryIdentification();
            ref1.ReferenceIdentificationQualifier_01 = "1G";
            ref1.MemberGrouporPolicyNumber_02 = "B99937";
            loop2300.AllNM1.Loop2310A.REF_AttendingProviderSecondaryIdentification.Add(ref1);

            //  End 2310A Loop

            //  Repeating 2320 Loops
            loop2300.Loop2320 = new List();

            //  Begin 2320 Loop OTHER SUBSCRIBER INFORMATION
            var loop2320 = new Loop_2320_837I();

            //  SBR OTHER SUBSCRIBER INFORMATION
            loop2320.SBR_OtherSubscriberInformation = new SBR_OtherSubscriberInformation_2();
            loop2320.SBR_OtherSubscriberInformation.PayerResponsibilitySequenceNumberCode_01 = "S";
            loop2320.SBR_OtherSubscriberInformation.IndividualRelationshipCode_02 = "01";
            loop2320.SBR_OtherSubscriberInformation.InsuredGrouporPolicyNumber_03 = "351630";
            loop2320.SBR_OtherSubscriberInformation.OtherInsuredGroupName_04 = "STATE TEACHERS";
            loop2320.SBR_OtherSubscriberInformation.ClaimFilingIndicatorCode_09 = "CI";

            //  OI OTHER INSURANCE COVERAGE INFORMATION
            loop2320.OI_OtherInsuranceCoverageInformation = new OI_OtherInsuranceCoverageInformation_2();
            loop2320.OI_OtherInsuranceCoverageInformation.BenefitsAssignmentCertificationIndicator_03 = "Y";
            loop2320.OI_OtherInsuranceCoverageInformation.ReleaseofInformationCode_06 = "Y";

            //  Occurrence of NM1 Loops in any order
            loop2320.AllNM1 = new All_NM1_837I_4();

            //  Begin 2330A Loop OTHER SUBSCRIBER NAME
            loop2320.AllNM1.Loop2330A = new Loop_2330A_837I();

            //  NM1 OTHER SUBSCRIBER NAME
            loop2320.AllNM1.Loop2330A.NM1_OtherSubscriberName = new NM1_OtherSubscriberName();
            loop2320.AllNM1.Loop2330A.NM1_OtherSubscriberName.EntityIdentifierCode_01 = "IL";
            loop2320.AllNM1.Loop2330A.NM1_OtherSubscriberName.EntityTypeQualifier_02 = "1";
            loop2320.AllNM1.Loop2330A.NM1_OtherSubscriberName.ResponseContactLastorOrganizationName_03 = "DOE";
            loop2320.AllNM1.Loop2330A.NM1_OtherSubscriberName.ResponseContactFirstName_04 = "JANE";
            loop2320.AllNM1.Loop2330A.NM1_OtherSubscriberName.ResponseContactMiddleName_05 = "S";
            loop2320.AllNM1.Loop2330A.NM1_OtherSubscriberName.IdentificationCodeQualifier_08 = "MI";
            loop2320.AllNM1.Loop2330A.NM1_OtherSubscriberName.ResponseContactIdentifier_09 = "222004433";

            //  N3 OTHER SUBSCRIBER ADDRESS
            loop2320.AllNM1.Loop2330A.N3_OtherSubscriberAddress = new N3_AdditionalPatientInformationContactAddress();
            loop2320.AllNM1.Loop2330A.N3_OtherSubscriberAddress.ResponseContactAddressLine_01 = "125 CITY AVENUE";

            //  N4 OTHER SUBSCRIBER CITY, STATE, ZIP CODE
            loop2320.AllNM1.Loop2330A.N4_OtherSubscriberCity_State_ZIPCode = new N4_AdditionalPatientInformationContactCity();
            loop2320.AllNM1.Loop2330A.N4_OtherSubscriberCity_State_ZIPCode.AdditionalPatientInformationContactCityName_01 = "CENTERVILLE";
            loop2320.AllNM1.Loop2330A.N4_OtherSubscriberCity_State_ZIPCode.AdditionalPatientInformationContactStateCode_02 = "PA";
            loop2320.AllNM1.Loop2330A.N4_OtherSubscriberCity_State_ZIPCode.AdditionalPatientInformationContactPostalZoneorZIPCode_03 = "17111";

            //  End 2330A Loop

            //  Begin 2330B Loop OTHER PAYER NAME
            loop2320.AllNM1.Loop2330B = new Loop_2330B_837I();

            //  NM1 OTHER PAYER NAME
            loop2320.AllNM1.Loop2330B.NM1_OtherPayerName = new NM1_OtherPayerName();
            loop2320.AllNM1.Loop2330B.NM1_OtherPayerName.EntityIdentifierCode_01 = "PR";
            loop2320.AllNM1.Loop2330B.NM1_OtherPayerName.EntityTypeQualifier_02 = "2";
            loop2320.AllNM1.Loop2330B.NM1_OtherPayerName.ResponseContactLastorOrganizationName_03 = "STATE TEACHERS";
            loop2320.AllNM1.Loop2330B.NM1_OtherPayerName.IdentificationCodeQualifier_08 = "PI";
            loop2320.AllNM1.Loop2330B.NM1_OtherPayerName.ResponseContactIdentifier_09 = "1135";

            //  End 2330B Loop

            //  End 2320 Loop
            loop2300.Loop2320.Add(loop2320);

            //  Repeating 2400 Loops
            loop2300.Loop2400 = new List();

            //  Begin 2400 Loop 1 SERVICE LINE
            var loop24001 = new Loop_2400_837I();

            //  LX SERVICE LINE COUNTER
            loop24001.LX_ServiceLineNumber = new LX_HeaderNumber();
            loop24001.LX_ServiceLineNumber.AssignedNumber_01 = "1";

            //  SV2 INSTITUTIONAL SERVICE
            loop24001.SV2_InstitutionalServiceLine = new SV2_InstitutionalServiceLine();
            loop24001.SV2_InstitutionalServiceLine.ServiceLineRevenueCode_01 = "0305";
            loop24001.SV2_InstitutionalServiceLine.CompositeMedicalProcedureIdentifier_02 = new C003_CompositeMedicalProcedureIdentifier_8();
            loop24001.SV2_InstitutionalServiceLine.CompositeMedicalProcedureIdentifier_02.ProductorServiceIDQualifier_01 = "HC";
            loop24001.SV2_InstitutionalServiceLine.CompositeMedicalProcedureIdentifier_02.ProcedureCode_02 = "85025";
            loop24001.SV2_InstitutionalServiceLine.LineItemChargeAmount_03 = "13.39";
            loop24001.SV2_InstitutionalServiceLine.UnitorBasisforMeasurementCode_04 = "UN";
            loop24001.SV2_InstitutionalServiceLine.ServiceUnitCount_05 = "1";

            //  DTP DATE - SERVICE DATES
            loop24001.DTP_Date_ServiceDate = new DTP_ClaimLevelServiceDate();
            loop24001.DTP_Date_ServiceDate.DateTimeQualifier_01 = "472";
            loop24001.DTP_Date_ServiceDate.DateTimePeriodFormatQualifier_02 = "D8";
            loop24001.DTP_Date_ServiceDate.DateTimePeriod_03 = "19960911";

            //  End 2400 Loop 1
            loop2300.Loop2400.Add(loop24001);

            //  Begin 2400 Loop 2 SERVICE LINE
            var loop24002 = new Loop_2400_837I();

            //  LX SERVICE LINE COUNTER
            loop24002.LX_ServiceLineNumber = new LX_HeaderNumber();
            loop24002.LX_ServiceLineNumber.AssignedNumber_01 = "2";

            //  SV2 INSTITUTIONAL SERVICE
            loop24002.SV2_InstitutionalServiceLine = new SV2_InstitutionalServiceLine();
            loop24002.SV2_InstitutionalServiceLine.ServiceLineRevenueCode_01 = "0730";
            loop24002.SV2_InstitutionalServiceLine.CompositeMedicalProcedureIdentifier_02 = new C003_CompositeMedicalProcedureIdentifier_8();
            loop24002.SV2_InstitutionalServiceLine.CompositeMedicalProcedureIdentifier_02.ProductorServiceIDQualifier_01 = "HC";
            loop24002.SV2_InstitutionalServiceLine.CompositeMedicalProcedureIdentifier_02.ProcedureCode_02 = "93005";
            loop24002.SV2_InstitutionalServiceLine.LineItemChargeAmount_03 = "76.54";
            loop24002.SV2_InstitutionalServiceLine.UnitorBasisforMeasurementCode_04 = "UN";
            loop24002.SV2_InstitutionalServiceLine.ServiceUnitCount_05 = "3";

            //  DTP DATE - SERVICE DATES
            loop24002.DTP_Date_ServiceDate = new DTP_ClaimLevelServiceDate();
            loop24002.DTP_Date_ServiceDate.DateTimeQualifier_01 = "472";
            loop24002.DTP_Date_ServiceDate.DateTimePeriodFormatQualifier_02 = "D8";
            loop24002.DTP_Date_ServiceDate.DateTimePeriod_03 = "19960911";

            //  End 2400 Loop 2
            loop2300.Loop2400.Add(loop24002);

            //  End 2300 Loop
            loop2000B.Loop2300.Add(loop2300);

            //  End 2000B Loop
            loop2000A.Loop2000B.Add(loop2000B);

            //  End 2000A Loop
            result.Loop2000A.Add(loop2000A);

            return result;
        }
    }
}

More operations in ediFabric .NET

837I questions

What is the difference between the 837I and the UB-04?

They carry the same data. The UB-04 (CMS-1450) is the paper form, the 837I (005010X223A2) is the HIPAA EDI format that replaces it for electronic submission.

How many service lines can an 837I claim have?

Up to 999 service lines (loop 2400) per claim. Each line is an SV2 segment with a revenue code, charge and units.

Where are the diagnosis and procedure codes in an 837I?

In the HI segments of loop 2300: principal diagnosis (ABK), admitting diagnosis (ABJ), other diagnoses (ABF) and ICD-10-PCS procedures (BBR, BBQ), together with condition, occurrence and value codes.

How do I parse and generate X12 837I files in .NET, Python, Java and C?

In .NET, install EdiFabric and EdiFabric.Templates.Hipaa, read the file with X12Reader into TS837I objects and write them back with X12Writer. From Python, Java or C, use ediFabric Native, which converts 837I files to JSON and JSON back to X12 inside your process. From any other language, post the file to the ediFabric Cloud REST API.

Related transactions

X12 837P - Health Care Claim: Professional
X12 837D - Health Care Claim: Dental
X12 835 - Health Care Claim Payment/Advice
X12 277CA - Health Care Claim Acknowledgment
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X12 837I Health Care Claim: Institutional Last updated: 2026-09-29