HIPAA EDI 837 / 835 Claims Quality
HIPAAfree17 data-quality rules for HIPAA X12N 837 healthcare claims and 835 remittance advice (ASC X12 5010 / TR3 companion guides). Covers NPI Luhn check, subscriber/member identifiers, ICD-10-CM diagnosis and CPT/HCPCS procedure code formats, place-of-service and claim-frequency codes, service and statement date ordering, charge and payment amount ranges, claim-level charge footing, CLP01 patient-control-number linkage between 837 and 835, CARC/RARC adjustment codes, gender-vs-diagnosis consistency, and duplicate claim suppression. Non-compliant claims are 277CA/999-rejected.
Checks included (17)
Service From Date <= Service To Date
The service "from" date must be on or before the service "to" date (Loop 2400 DTP*472). Reversed service dates are rejected.
Service Date Not After Statement Date
A service date cannot be after the claim statement/creation date; a service dated in the future relative to submission is invalid.
Claim Total Charge Equals Sum Of Lines
The claim total charge (CLM02) must equal the sum of service-line charges (SV102). A footing mismatch triggers claim rejection.
Gender Consistent With Diagnosis
Sex-specific diagnosis codes must match subscriber gender (e.g., pregnancy O00-O9A or Z34 only for female; prostate C61/N40 only for male). Mismatches trigger CMS gender/diagnosis edits.
835 Paid + Adjustments = Charge
For each 835 claim payment, the reported charge (CLP03) must equal the paid amount (CLP04) plus patient responsibility plus the sum of CAS adjustment amounts. The remittance must balance at claim level.
Date Of Birth Before Service Date
The patient date of birth must be on or before the earliest service date; a service dated before birth is impossible and indicates a data error.
Billing Provider NPI Passes Luhn
The billing provider NPI (Loop 2010AA NM109) must be a 10-digit number passing the Luhn check with the 80840 prefix per the CMS NPI check-digit algorithm.
Diagnosis Code Is ICD-10-CM Format
Principal/other diagnosis codes (Loop 2300 HI ABK/ABF) must match the ICD-10-CM pattern: a letter, two digits, optional dot and up to four alphanumerics.
Procedure Code Is CPT / HCPCS Format
Service-line procedure codes (Loop 2400 SV101-2) must be a 5-digit CPT code or a HCPCS Level II code (letter followed by four digits).
Place Of Service Code Valid
The place-of-service code (Loop 2300 CLM05-1) must be a valid two-digit CMS POS code (e.g., 11 office, 21 inpatient, 22 outpatient, 23 ER, 12 home).
Claim Frequency Code Valid
The claim frequency type code (CLM05-3, third digit of the bill type) must be a valid NUBC value: 1 (original), 7 (replacement), 8 (void).
Line Charge Amount Positive
Each service-line charge amount (SV102) must be greater than zero; a zero/negative charge on a billed line is invalid.
Service Units (SV104) Positive Integer
The service units/days (SV104) must be a positive quantity; zero or negative units on a billed line are invalid.
835 Patient Control Number References Claim
The 835 remittance CLP01 patient control number must reference a submitted 837 claim. An 835 line that matches no claim cannot be posted.
Adjustment Reason Code (CARC) Valid
Each CAS claim adjustment reason code (CARC) must exist in the current X12 Claim Adjustment Reason Code list. Retired/invalid CARCs are rejected.
Subscriber / Member Id Present
The subscriber primary identifier (Loop 2010BA NM109) must be present; claims with no member ID cannot be adjudicated.
Patient Control Number Unique
The patient control number / claim ID (CLM01) must be unique per billing provider; duplicates indicate a resubmission that should use a replacement frequency code instead.