CurrentsanfranciscohealthplanPolicy 4
837 Professional Claims/Encounters HIPAA Companion Guide
Customize your policy alerts
Sign up for sanfranciscohealthplan Policy 4 alerts
Get alerted when Policy 4 changes without checking for updates manually.
Monitor payer policy activity
Receive email alerts as soon as relevant payer policies are published or updated.
Defines SFHP requirements and implementation details for submitting 837 Professional claim and encounter electronic transactions (ASC X12 005010X222A1) to San Francisco Health Plan; applies to SFHP trading partners and submitters exchanging 837P files with SFHP.
Policy Summary
Payersanfranciscohealthplan
Policy837 Professional Claims/Encounters HIPAA Companion Guide
Policy CodePolicy 4
Change TypeNo material coverage changes
Effective DateMay 14, 2021
Last ReviewMay 14, 2021
Next Review DateMay 14, 2021
Key ActionEnsure Billing Provider NPI is provided; claims will be rejected if Billing Provider NPI is missing.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
005010X222A1Implementation Guide
2.5Companion Guide version
2Min test cycles
10:30 AMCutoff time
SFTPTransport
RequiredNPI required
Submission and Claim Validation Rules
inv-01: Submission and validation criteria
Validation, required/situational usage, and acceptable data rules governing submission and processing of 837P files to SFHP.
Files must follow industry standard practices for line, segment and element terminators; carriage return/line feed allowed; ISA header must allow dynamic determination of segment, element and sub-element terminators.
Sending data with a non-standard ISA header where terminators cannot be dynamically determined will result in rejection of the entire file.
If additional data is sent in standard 005010X222A1-defined 837P format, SFHP will ignore additional fields until mutually agreed; data not defined in the Implementation Guide will cause file rejection.
Loops, segments and elements are marked Required or Situational; if a situational loop is used, any elements within it marked Required must be populated (example: REF*F8 is required when submitting replacements/voids).
Pre-processor validation enforces HIPAA compliance, member match and provider match; claims/encounters failing pre-processor validation will be rejected and returned to the submitter.
Processing window: claims and professional encounters received before 10:30 AM on a business day are processed same day by 6:00 PM; those received after 10:30 AM are processed next business day by 6:00 PM.
Encounters routed to SFHP Enterprise Data Warehouse are validated for HIPAA compliance; failures are returned to submitter via error reports on the following business day.
SFHP exchanges claims and encounters via SFTP; a Trading Partner Agreement is required prior to SFTP setup and connectivity.
Onboarding requires submission of 837P Enrollment including provider Tax ID; SFHP requests test files and requires a minimum of two successful test cycles before production approval.
Filename/naming conventions and header specifications (ISA/GS/ST values and example elements) are documented and must be followed (e.g., ISA12='00501', GS08='005010X222A1').
inv-02: Claim data population and validation rules
Claim-level data population requirements and situational elements
CLM01 (Patient Control Number) is required and must be populated.
CLM02 (Total Claim Charge Amount) is required and must be populated.
CLM05-1 (Facility Code Value) is required; populate with the appropriate facility code (examples provided: '11' Office; '21' Inpatient Hospital; '22' Outpatient Hospital; '23' ER Hospital; etc.).
CLM05-3 (Claim Frequency Type Code) is required and must reflect correct frequency (e.g., '1' Original, '6' Corrected, '7' Replacement, '8' Void).
CLM06 (Provider or Supplier indicator) is required and must be set appropriately ('Y' or 'N').
Reference segments (situational)
- REF*G1 (Prior Authorization) is situational; when applicable include REF*G1*
at claim level. - REF*F8 (Original Reference Number) is required when submitting adjustments/voids; use original CLM01 for encounters or adjudication system ID for claims as applicable.
NPI is required for referring, rendering, service facility, billing and other providers; absence of required NPI will cause claim rejection by SFHP.
inv-03: Claim submission criteria
Submission requirements and situational/required elements for claim loops
Provider NPI must be provided for all applicable provider loops; missing NPI will result in claim rejection by SFHP.
2310B.PR V (service facility/provider taxonomy) must be populated when required; use PRV*PE*PXC* for rendering/provider taxonomy where indicated.
Inclusion of the 2320 COB loop is required when applicable for coordination of benefits; when 2320 is used, include 2330A/2330B loops as required.
2400.SV1 (service line) is required for professional service lines: include service ID qualifier 'HC' and procedure code; SV102 (line item charge amount) and SV103 (unit basis) must be populated.
Drug reporting when applicable
- When SV1/HCPCS indicates a physician-administered drug, include 2410 LIN/CTP to report NDC (LIN N4) and drug quantity (CTP).
- Service line REF/DTP usage: include DTP.G1 at the service line level to reference prior authorization when applicable (G1 = prior authorization number).
Populate service-level rendering/provider loops (2420 subloops) when rendering provider differs from claim-level or when required; ensure the rendering provider NPI is present or claim will be rejected.
inv-04: Submission and validation rules
Submission requirements and conditional behaviors documented in the companion guide.
Billing Provider NPI is required; claims missing the Billing Provider NPI will be rejected by SFHP.
ICD code version is determined by date of service: use ICD-10 for DOS on or after 2015-10-01 and ICD-9 for DOS before 2015-10-01; encounters/claims using the wrong code set will be denied.
Populate the 2420C NM1 '77' Service Facility Location loop when the service facility differs from the claim-level or billing provider; include NPI in NM109/NM1 as required.
inv-05: Informational Appendices
Informational appendices only; no coverage decisions are specified in these excerpts.
Includes an illustrative sample 837 claim modified for newborn services to guide electronic submission; this is informational and not a coverage decision.
Appendix contains HCPCS-to-NDC crosswalk references (dmepdac.com) and sample mappings; these are provided as examples and informational resources only.
Codes, Identifiers, and Versioning
Implementation guidemixed
| 005010X222A1 | X12 Implementation Guide referenced for 837 Professional transactions |
EDI/Transaction set codes referencedmixed
| 00501 | Interchange Control Version Number example (ISA12) |
| 005010X222A1 | Implementation/Transaction set version (GS08/ST03) |
| 837 | Health Care Claim transaction set (ST01) |
Diagnosis code qualifiersICD-10
| ABF / ABK | ICD-10-CM diagnosis code qualifiers referenced in HI segments |
| BF | ICD-9-CM diagnosis code qualifier (legacy) |
Service and drug identifiersmixed
| HC | HC = Health Care Financing Administration Common Procedural (Service ID Qualifier for SV101-1) |
| N4 | N4 = National Drug Code in 5-4-2 format (LIN ID Qualifier for NDC) |
| EN | EN = EAN/UCC-13 (UPN) |
Service line procedure identifiersmixed
| HCPCS | Procedure/Product codes used in SVD03 and related modifier fields at service line |
Diagnosis coding complianceICD-10Covered
| ICD-10 | Diagnosis codes required for DOS on/after 2015-10-01; ICD-9 required before that date |
inv-13: ISA/GS/Version requirements
ISA Interchange Control VersionISA12 must contain value '00501'
GS Functional Group VersionGS08 must reference '005010X222A1' as the functional group/implementation guide
GS Functional IDGS01 must use 'HC' for Health Care Claim (837)
inv-14: SV102 requirement
SV102 elementSV102 (Line Item Charge Amount) is required on every service line
SV101 service IDSV101 must include Service ID Qualifier (e.g., 'HC') and the procedure code
SV103 unitsSV103 (Unit or Basis for Measurement) is required (examples: 'UN' = Unit, 'MJ' = Minutes)
inv-15: ICD version by date of service
ICD version ruleUse ICD-10 diagnosis codes for DOS on or after 2015-10-01; use ICD-9 codes for DOS before 2015-10-01
Noncompliance effectEncounters/claims using incorrect ICD version for DOS will be denied
Compliance dateICD-10 compliance effective date: October 1, 2015
inv-16: Crosswalk source
Crosswalk source URLDMEPDAC NDC/HCPCS Crosswalk: https://www.dmepdac.com/crosswalk/index.html (choose latest year)
Usage noteSelect the latest year files from the DMEPDAC NDC/HCPCS Crosswalk for up-to-date mappings
PurposeUse crosswalk to map HCPCS codes to equivalent NDC codes for physician-administered drugs
Trading Partner Setup and Submission Actions
Documentation Required
Trading partner setup and test requirements
Trading Partner Agreement must be signed prior to SFTP connectivity. Submit the 837P Enrollment (including provider Tax ID). SFHP will request an 837P test file and a minimum of two successful test cycles are required before production 837P exchange is approved.
- Complete and sign the Trading Partner Agreement before SFTP setup.
- Submit 837P Enrollment with Health Care Professional Tax ID.
- Provide an 837P test file and complete at least two successful test cycles to gain production access.
Documentation Required
Ensure NPI provided
Provide an NPI for the Billing Provider and all providers included on the claim; absence of the Billing Provider's NPI will cause the claim to be rejected by SFHP.
- Ensure NM109/NM108 contains the Billing Provider NPI (qualifier 'XX').
- Populate NPI for rendering, supervising, and other provider loops as required.
Prior Authorization
Prior Authorization REF segment
When a prior authorization exists at the claim level, include REF*G1*
- Use REF01 = 'G1' and REF02 =
at 2300 when applicable.
Documentation Required
Original reference for adjustments/voids
For adjustments or voids of previously submitted records, include REF*F8*
- Use REF qualifier 'F8' with the original claim or adjudication ID as REF02 when replacing or voiding.
- For encounters to EDW, use the original CLM01 value.
Prior Authorization
Prior authorization reference
If a prior authorization applies at the service line level, include the prior authorization number in the service line DTP as qualifier G1.
- Populate 2400 DTP with DTP01 = '472' (Service Date) and use the Authorization Reference element with qualifier 'G1' to carry the prior authorization number when applicable.
Denial Risk
NPI requirement / claim rejection
Ensure the Billing Provider NPI is provided in the billing provider loops; SFHP will reject claims that do not include the Billing Provider's NPI.
- Populate NPI in 2010AA (Billing Provider) and in any 2420 provider loops as required.
- Validate that the Billing Provider NPI is present before submission to avoid rejection.
Documentation Required
Sample Claim for Newborn Services
Refer to the sample 837 transaction provided (Sample Claim Modified for Newborn Services) for an illustrative 837 claim showing segments and elements when services are for a newborn; use this example to guide electronic claim submission.
- Review the Sample Claim Modified for Newborn Services for correct use of 2000C/2010CA newborn patient loops and related segments.
- Follow the sample's segment structure and element usage when submitting newborn claims electronically.
Segment, Loop, and Field Definitions
inv-24: Companion Guide
Companion Guide purposeThis Companion Guide supplements the X12 5010 837 Professional Implementation Guide and specifies SFHP-required elements for 837P exchange
ScopeProvides SFHP-specific data element requirements, file naming, transport, validation, and processing expectations
Not a substituteNot representative of full X12 5010 TR3; use alongside the X12 5010 837 TR3
inv-25: File header segments
ISA11 repetitionISA11 (Interchange Control Number repetition) is assigned by the sender and must match IEA02
GS functional ID exampleGS01 should be 'HC' for Health Care Claim (837)
Version examplesISA12 example '00501'; GS08 example '005010X222A1'
inv-26: ISA12
ISA12 definitionISA12 = Interchange Control Version Number; instructions & examples show value '00501'
Required statusISA12 is a required element in the ISA segment
Related elementISA12 value aligns with GS/ST usage in file headers and implementation guide references
inv-27: 1000A / 1000B
1000A submitter loop1000A NM1 contains Submitter name and NM109 holds ETIN (example: NM1*41*2*SAN FRANCISCO HOSPITAL*****46*987654321)
1000A contact1000A PER provides submitter EDI contact details (example: PER*IC*BUSINESS OFFICE*TE*4156154411)
1000B receiver loop1000B NM1 contains Receiver name and NM109 identifies SFHP (example: NM1*40*2*SF HEALTH PLAN*****46*SFHP)
inv-25: 2010AA / 2010AB
Billing provider NM12010AA NM1 must include Billing Provider NPI in NM108 using qualifier 'XX' (example: NM1*85*2*...*XX*1234567890)
Physical address requirement2010AA N3/N4 require a physical billing provider address (N3 example: '10 3RD AVE')
Remit/Pay-To loop2010AB used for Pay-To information; remit address guidelines provided in billing provider details
inv-29: 2000C / 2010CA
Patient hierarchical loop usage2000C / 2010CA patient loops are used only when services are provided to a newborn whose mother is an SFHP subscriber
HL values for newborn2000C HL01 will carry value '3' for newborn dependent example
PAT segment2000C PAT segment used to indicate individual relationship (example: PAT*19 for Child)
inv-30: Newborn handling
Newborn-only segments2000C and 2010CA segments are only used when service is for a newborn whose mother is an SFHP subscriber
Patient name loop2010CA NM1 uses 'QC' qualifier for Patient (example: NM1*QC*1*DOE*JANE~)
Address requirement2010CA includes N3/N4 patient address elements when used for newborn records
inv-31: NPI requirement
NPI requirementNPI (National Provider Identifier) is required for all providers; missing NPI will cause claim rejection by SFHP
Providers impactedReferring, Rendering, Service Facility and Billing provider NM1 loops must include NPI where applicable
Error consequenceClaims lacking required NPI identifiers are rejected during pre-processor validation
inv-32: NPI
NPI enforcementNational Provider Identifier is required for all providers; absence will cause claim rejection by SFHP
NM108 qualifierUse qualifier 'XX' in NM108 to indicate NPI in provider name loops
Rendering/provider loopsEnsure NPI present in 2310/2420 loops as applicable to avoid rejections
inv-33: SV1 segment
SV1 segment contentSV1 is the professional service line segment containing procedure code in SV101 and charge amount in SV102
SV101 qualifierSV101-1 must use 'HC' for HCPCS/Procedure qualifier when applicable
Service line unitSV103 (Unit or Basis for Measurement) and SV104 (Service Unit Count) are required
inv-34: LIN/CTP segments
Drug reporting segmentsUse LIN (with N4/N4 qualifier) to report NDC and CTP to report drug quantity on service lines when SV1 HCPCS indicates physician-administered drugs
LIN exampleLIN**N4*00001234567~ shown to specify NDC code for physician-administered drugs
CTP quantityCTP segment (e.g., CTP****2*UN~) carries the drug quantity and unit basis
inv-35: 2420A/2420B/2420C Provider Name/ID loops
2420 provider loops2420A/2420B/2420C loops contain provider name/ID details (NM1 segments such as NM1*82 for Rendering Provider)
NM109 ID usageNM109 holds provider identification (NPI) and NM108 uses qualifier 'XX' for NPI
Conditional requirements2420 loops are required when service-level provider differs or is required by loop rules
inv-36: 2430 CAS / DTP
CAS segment roleCAS provides line adjustment group, reason codes, amounts and quantities for line-level adjustments
DTP segment roleDTP carries adjudication/payment or service dates (date qualifiers used at line/claim level)
CAS exampleExample CAS segment: CAS*PR*1*10.00~
inv-37: EDI Delimiters
Data element delimiterUse '*' as data element separator, '>' as component element separator, and '~' as segment terminator as shown in ISA/GS/ST examples
ISA fixed lengthISA is a fixed record length segment and all positions must be space filled
Delimiter examplesExample ISA/segment usage shows delimiters in file header samples
inv-38: HCPCS/NDC Crosswalk
HCPCS to NDC crosswalk referenceHCPCS↔NDC crosswalk available from DMEPDAC (https://www.dmepdac.com/crosswalk/index.html); choose latest year
PurposeUse crosswalk for physician-administered drug reporting when HCPCS indicates an NDC is required
Sample mappings includedAppendix C provides sample HCPCS to NDC relationships for reference
inv-39: Sample 837 Claim (Newborn)
Sample newborn 837Sample 837 claim modified for newborn services is provided as an illustrative transaction showing ISA/GS/ST through service lines and newborn loops
Included elementsSample shows NM1 billing/receiver, HL loops, PAT for newborn and multiple SV1 service lines with DTP/REF elements
Use as guidanceUse the sample transaction to guide electronic claim submission for newborn services to SFHP
Policy Summary
Payersanfranciscohealthplan
Policy837 Professional Claims/Encounters HIPAA Companion Guide
Policy CodePolicy 4
Change TypeNo material coverage changes
Effective DateMay 14, 2021
Last ReviewMay 14, 2021
Next Review DateMay 14, 2021
Key ActionEnsure Billing Provider NPI is provided; claims will be rejected if Billing Provider NPI is missing.
SourceLink
On This Page
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.