Section title: Requests for Interpretation
RFI #
2331
Patient Out of Network claim - 827
Description

Could a patient submit a out of network claim reimbursement using the X12 837?

Response

The Front Matter Section 1.4 Business Usage of the 837 Health Care Claim Transaction(s) states that the transaction is designed “…to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billing services and claims clearinghouses”.  Based on this requirement the Patient cannot be the submitter of the X12 837 transaction.

DOCUMENT ID
005010X222