Healthcare Claims Format: How Claims Are Sent to Payers

Healthcare Claims Format: Ever wondered how your medical bills travel from the doctor’s office to your insurance company? It’s not magic; it’s paperwork, and there is lots of it.

Behind every doctor visit, lab test, or hospital stay, a system works quietly in the background to ensure providers get paid. This system depends on healthcare claims, the official requests for reimbursement sent from healthcare providers to insurance payers. These claims follow a specific format, and choosing the correct one is crucial for timely payments and avoiding denials. Yet, many people, even those in healthcare, don’t fully understand how these claims are sent.

Healthcare claims are submitted in two ways: electronically and manually. Electronic claims use formats like 837P for professional services and 837I for institutional care, ensuring fast and accurate data exchange. Manual claims are submitted on paper forms like CMS-1500 and UB-04, typically used when electronic submission isn’t possible.

What Does “Format” Mean in Healthcare Claims?

In healthcare billing, the term “format” refers to the standardized structure used to submit claims from healthcare providers to insurance payers. It defines how the required information, such as patient details, diagnosis codes, procedures, and charges, is organized, presented, and transmitted, whether on paper or electronically.

Two Main Types of Medical Claim Formats

1. Paper Claim Formats:

Standardized physical forms like CMS-1500 (for individual providers) and UB-04 (for hospitals) are used to submit claims manually.

2. Electronic Claim Formats:

Digital, standardized files such as ANSI X12 837 and NCPDP are used for faster, accurate electronic claim submissions.

Why Format Matters

Standardized claim formats ensure:

• Consistency in how data is submitted across providers
  
• Compliance with industry regulations (such as HIPAA)
  
• Efficient processing and fewer errors or denials from payers

Common Formats Used to Submit Healthcare Claims

When healthcare providers deliver services to patients, they must submit claims to insurance companies (payers) to get paid. These claims follow standardized formats to ensure accuracy, consistency, and compliance. Each type of service, whether it’s a doctor’s visit, hospital stay, or prescription, uses a specific claim format.

1. CMS-1500 (Professional Claims)

This format is used by individual healthcare providers like physicians, therapists, and other outpatient service providers. It captures details like the patient’s information, diagnosis codes, procedures performed, and charges.

• Format Type: Paper or electronic
  
• Electronic Version: ANSI X12 837P
  
• Used For: Outpatient and professional services

2. UB-04 / CMS-1450 (Institutional Claims)

Hospitals and other facilities use the UB-04 form to bill for inpatient, outpatient, and emergency services. It includes more complex billing data such as room charges, lab services, and surgical procedures.

• Format Type: Paper or electronic
  
• Electronic Version: ANSI X12 837I
  
• Used For: Hospital and facility-based services
  

3. ANSI X12 837 (Electronic Claim Formats)

This is the HIPAA-compliant electronic standard for all claim types. It includes:

• 837P (Professional) – For individual provider services
  
• 837I (Institutional) – For facility-based services
  
• 837D (Dental) – For dental procedures

4. NCPDP (Pharmacy Claims)

Pharmacies use this format to submit claims for prescription medications. It supports real-time processing and ensures that medications are billed accurately.

• Format Type: Electronic
  
• Standard: NCPDP Telecommunication Standard
  
• Used For: Prescription drug claims

Types of Electronic Medical Claim Formats

Electronic medical claim formats are standardized digital files that healthcare providers use to submit billing information to insurance companies. These formats ensure claims are processed accurately, securely, and efficiently. The main electronic claim formats are regulated under HIPAA and developed by the Accredited Standards Committee (ASC) X12.

ANSI X12 837P (Professional Claims)

This format is used by individual healthcare providers such as doctors, therapists, and other outpatient service providers. It is designed for billing professionals and outpatient services.

• Who uses it? Physicians, therapists, and non-institutional providers
  
• Purpose: To bill for office visits, consultations, and outpatient procedures
  
• Paper equivalent: CMS-1500 form

ANSI X12 837I (Institutional Claims)

Hospitals and healthcare facilities use this format to submit claims for inpatient stays and other facility-based services.

• Who uses it? Hospitals, skilled nursing facilities, rehabilitation centers
  
• Purpose: To bill for hospital stays, surgeries, emergency room visits, and other institutional services
  
• Paper equivalent: UB-04 (CMS-1450) form

ANSI X12 837D (Dental Claims)

This format is used by dental providers to submit claims for dental services and procedures.

• Who uses it? Dentists and oral health providers
  
• Purpose: To bill for dental exams, cleanings, fillings, and other dental care

NCPDP (Pharmacy Claims)

Pharmacies use this electronic format to submit claims for prescription medications. It supports real-time processing at the point of sale.

• Who uses it? Pharmacies
  
• Purpose: To bill for prescription drugs and medications
  
• Standard: NCPDP Telecommunication Standard

Standardization of Healthcare Claim Formats

The healthcare claim format, both paper and electronic, is determined and maintained by specific regulatory and standard-setting organizations in the United States. These include:

Entity/Standard	Role/Responsibility	Description
NUCC (National Uniform Claim Committee)	Designs and maintains the CMS-1500 form	Ensures a consistent paper claim format for non-institutional providers and suppliers
CMS-1500 Form	Standard paper claim form	Used by non-institutional providers for billing Medicare and Durable Medical Equipment Regional Carriers (DURC)
NUCC Website	Provides guidance	Offers official instructions for completing the CMS-1500 form
ASC X12N 837P (Professional)	Electronic claim format	Current version: 5010A1; standard for professional electronic healthcare claims
ANSI (American National Standards Institute)	Oversees electronic standards	ANSI’s Accredited Standards Committee X12 develops standards like the 837P
HIPAA (Health Insurance Portability and Accountability Act)	Enforces standardization	Requires the use of electronic transaction standards such as ASC X12N 837 Version 5010

Medical Claim Formats

Paper Claim Form	Electronic Format
CMS-1500	ANSI X12 837P
Professional services	Professional services (e.g. hospital stays)
UB-04 (CMS-1450)	ANSI X12 837I
Institutional services	Institutional services (e.g. hospital stays)
ADA Dental Form	ANSI X12 837D
Dental procedures	Dental procedures

Claim Submission Workflow: How Claims Are Sent

Once a claim is properly formatted (e.g., 837P or CMS-1500), it’s transmitted to payers using one of the following methods:

• Clearinghouses:
  Act as intermediaries, check claims for errors, and forward clean ones to payers, reducing denials.
  
• EDI (Electronic Data Interchange):
  Enables direct, secure, automated claim submission to payers without paper.
  
• Payer Portals:
  Web platforms where providers manually submit claims are often used by smaller practices or for special cases.

Common Errors & Rejections in Claim Formatting

Incorrect claim formatting can lead to rejections or delays in reimbursement. Here are some frequent mistakes and how to avoid them:

• Missing or incorrect patient information (e.g., date of birth, insurance ID)
  → Double-check all demographic data before submission.
  
• Invalid or outdated diagnosis/procedure codes
  → Use current ICD-10, CPT, and HCPCS codes.
  
• Incorrect claim format (e.g., using CMS-1500 for hospital services)
  → Match the format to the service type (837P, 837I, etc.).
  
• Incomplete provider or payer details
  → Ensure NPI, taxonomy, and payer IDs are accurate.

Standards Updates & Future Trends

The healthcare industry is evolving to improve claim accuracy, speed, and interoperability. Key trends include:

• ASC X12 Updates:
  New versions of the 837 claim formats (like 7030) are in development to enhance data exchange and compliance.
  
• FHIR-Based Claim Transactions:
  Fast Healthcare Interoperability Resources (FHIR) is emerging as a modern standard, enabling real-time, API-driven data sharing between providers and payers.

Final Thought

Submitting healthcare claims might seem like a behind-the-scenes task. Still, it’s the backbone of how providers get paid and patients receive the care they need without financial confusion. Understanding the correct claim formats whether it’s 837P, 837I or CMS-1500 not only ensures smoother billing but also keeps providers compliant and reimbursed on time. As the industry moves toward greater automation and interoperability, mastering these formats today sets the stage for a more efficient and connected healthcare system tomorrow.

How CloudRCM Helps with Claim Submission

CloudRCM handles both electronic (837P/837I) and manual (CMS-1500/UB-04) claim submissions with precision, ensuring faster payments and fewer denials management. What sets us apart is our use of automation, expert compliance checks, and real-time support, making the entire billing process smoother and more efficient for healthcare providers.

FAQs:

What claim form is used for physician claims?

Physician claims are submitted using the CMS-1500 form (or electronically as ANSI X12 837P) for billing professional outpatient services.

In what format are healthcare claims sent?

Healthcare claims are sent electronically using standardized formats such as ANSI X12 837.

How are health claims submitted?

Health claims are submitted electronically through methods like EDI, clearinghouses, or payer portals.

What is the EDI format for healthcare?

The EDI format for healthcare claims is the ANSI X12 837 transaction set.

What is the standard format used for the submission of electronic claims for professional healthcare?

The standard electronic claim format for professional healthcare is ANSI X12 837P.