Missing Identity
If patient, subscriber, provider, or payer identity is ambiguous, expect routing or matching problems before adjudication.
Reference 0002
837P Data Checklist
A practical EMR-to-claim readiness checklist for professional claims. Use it before thinking about X12 segment syntax.
This checklist is intentionally product-oriented: it tells you what data buckets your workflow must collect and validate.
The Five Buckets
| Bucket | Typical Data | Product Readiness Question |
|---|---|---|
| Provider | Billing provider, rendering provider, NPI, taxonomy when needed, service facility when needed. | Do we know who is billing, who performed the service, and where the service happened? |
| Patient | Patient identity, date of birth, sex, address, relationship to subscriber. | Can the payer match the person who received care? |
| Payer | Payer, plan, subscriber/member ID, subscriber demographics, coordination of benefits when relevant. | Can the claim route to the right payer under the right member coverage? |
| Diagnosis | ICD-10-CM diagnosis codes in priority order, diagnosis pointer from service lines to diagnoses. | Does the claim explain why the services were medically relevant? |
| Service | Date of service, place of service, CPT/HCPCS code, modifiers, units, charge, NOC description when needed. | Does every line say what was done, where, when, how many, and for how much? |
Validation Heuristics
Missing Medical Reason
If diagnosis and diagnosis pointers are absent or inconsistent, the service line lacks the medical why.
Missing Line Detail
If date, POS, procedure, units, modifiers, or charge are wrong, the payer cannot price or adjudicate the line correctly.
Source Anchors
- CMS MLN Claim Completion groups successful claim submission data into professional/supplier, patient, and payer information.
- CMS MLN Billing Information lists claim billing data including diagnosis, procedures, dates of service, charges, days/units, total charge, and amount paid.
- CMS MLN Essential Claim Fields maps fields such as diagnosis, dates of service, place of service, and procedures to 837P loops and CMS-1500 items.
- NUCC 1500 Instruction Manual is the standard reference for professional claim form completion.