Repricing an 837I: what the claim file carries and what pricing still needs
The 837I gives you codes, dates, discharge status and charges. Pricing also needs the hospital’s CCN, the payment year and the plan’s own rules. A field-by-field checklist with a sample claim you can parse live.
- Applies to
- Institutional claims (837I or UB-04)
- Example
- Synthetic inpatient claim, no patient data
- Grouper
- Chosen by discharge date
On this page
What the 837I carries
An 837I, the electronic version of the UB-04 institutional claim, carries almost everything a Medicare-based price depends on. Here is where to find each piece:
| Pricing needs | Where it is on the 837I | Why it matters |
|---|---|---|
| Type of bill | CLM05: facility code and frequency | 11x is an inpatient stay priced by MS-DRG; 13x is hospital outpatient, priced line by line. The third digit is the frequency: 1 a complete stay; 2, 3 and 4 interim bills on a long stay (do not price one as a complete stay); 7 a replacement (re-price and adjust the original); 8 a void (reverse the original) |
| Statement period | DTP*434 | The “through” date is the discharge date for a complete stay; it picks the rate year |
| Admission date | DTP*435 | With the discharge date, gives the length of stay |
| Discharge status | CL1, third element | Drives the transfer rule |
| Diagnoses and present-on-admission flags | HI with qualifiers ABK (principal) and ABF (others) | Grouping; the flag rides in the ninth component |
| Procedures and their dates | HI with qualifiers BBR (principal) and BBQ (others) | Grouping for surgical MS-DRGs |
| Billed MS-DRG | HI with qualifier DR | The hospital’s expected DRG, to compare with yours |
| Total charges | CLM02 | Covered charges for the outlier, once non-covered amounts come off |
| Service lines | SV2: revenue code, HCPCS, charge, units, non-covered amount | Outpatient pricing; covered charges |
| Value, condition and occurrence codes | HI with qualifiers BE, BG, BH and BI | Covered and non-covered days, information-only Medicare Advantage claims, qualifying dates |
| Patient age and sex | DMG | Grouping edits, such as age- and sex-specific codes |
| Billing provider | NM1*85 with the NPI | Identifies the hospital, but not by CCN |
What it does not carry
- The CCN. Medicare’s hospital payment factors hang off the six-digit CMS certification number, but the 837I names the billing hospital by NPI. A repricer needs an NPI-to-CCN match, and one hospital can bill under more than one NPI. Medicaid programs add their own identifiers: New York and Texas price hospitals by state numbers, not the CCN.
- The hospital’s payment factors. Wage index, teaching and low-income add-ons, uncompensated care, cost-to-charge ratios and the pass-through per diem come from the hospital’s provider record for the discharge date, not from the claim.
- The rate year and grouper version. You derive them from the discharge date (see which year’s rates apply).
- The plan’s terms. Original Medicare or Medicare Advantage basis, percentage, carve-outs and lesser-of tests are not on the claim (see reference-based pricing).
A sample claim, parsed
Here is a synthetic inpatient 837I, with no real patient behind it (the birth date is made up and there is no name or member ID): a sepsis stay with acute respiratory failure, admitted October 10 and discharged October 15, 2026, billed at $95,000 with MS-DRG 871. It is trimmed to the segments pricing reads, with no interchange envelope, submitter or receiver, hierarchical (HL) loops or subscriber loop, so an EDI validator will reject it as it stands.
ST*837*0001*005010X223A2~ BHT*0019*00*0123*20261019*1200*CH~ NM1*85*2*GENERAL HOSPITAL*****XX*1234567893~ CLM*WEB-DEMO-1*95000.00***11:A:1**A*Y*Y~ DTP*434*RD8*20261010-20261015~ DTP*435*D8*20261010~ CL1*1*1*01~ DMG*D8*19520301*F~ HI*ABK:A419:::::::Y~ HI*ABF:J9601:::::::Y*ABF:E119:::::::Y*ABF:I10:::::::Y~ HI*DR:871~ SE*12*0001~
Parsed and regrouped, it reads as an inpatient Part A claim, bill type 11x, a 5-day stay with discharge status 01 and four diagnoses, all present on admission. The engine picks MS-DRG version 44 from the discharge date and regroups the codes to MS-DRG 871, the DRG the hospital billed; acute respiratory failure with hypoxia (J96.01) is the MCC that sets the level.
The claim names the hospital only by NPI (1234567893, a test number). Priced at NewYork-Presbyterian Hospital (CCN 330101), the same stay is $28,176.18 in Original Medicare and $20,580.12 for a Medicare Advantage plan paying out of network.
The steps a repricer runs
- Parse the file and check its structure. Hold claims missing a discharge date, a discharge status or a principal diagnosis.
- Read the frequency digit of the type of bill. Match replacement and void claims to the original before pricing, and do not price an interim bill as a complete stay.
- Identify the hospital: match the NPI to a CCN.
- Pick the rate year and grouper version from the discharge date.
- Regroup the codes and compare with the billed DRG; route mismatches and single-MCC claims to review (DRG validation).
- Price: the DRG, the outlier from covered charges, the transfer rule from the discharge status (the per-diem rule), and the pass-through from covered days.
- Apply the plan’s terms: basis, percentage, carve-outs, lesser-of.
- Keep the inputs, versions and components with the claim, so the result can be explained on appeal.
Outpatient claims
A 13x outpatient claim is priced line by line: each SV2 line gets a status indicator and an APC, packaging and multiple-procedure rules apply across the claim, and code-pair and unit edits run first. Every line needs its own date of service: rates are set by calendar year and updated each quarter, and each line prices on the quarterly table for its own date. The Outpatient pricer and Claim import on this site handle these claims, and the site-of-service gap shows what the same procedure pays in a hospital outpatient department and in an ASC.
Claim files are protected health information
Real 837 files contain protected health information. The tools on this site keep claim content out of links and out of browser storage, and share links carry codes only. The sample above is synthetic.
Questions
Does an 837I contain the hospital’s CCN?
Not as a standard field for Medicare pricing. The billing hospital is identified by NPI, and the CCN that carries its payment factors comes from a match.
How is the length of stay calculated?
The discharge date minus the admission date; the day of discharge is not counted. Covered days can be fewer, which the claim reports in value codes.
Which grouper version should a repricer use?
The version in force on the discharge date: MS-DRG version 44 for discharges from October 1, 2026.
What is the difference between the billed and the regrouped DRG?
The billed DRG is what the hospital put on the claim. The regrouped DRG is what your grouper assigns from the claim’s codes; a difference needs review.
About these figures
The sample claim is synthetic and was parsed and grouped, not priced, by the cmswebpricer.com engine on October 19, 2026. The Original Medicare and Medicare Advantage amounts come from a separate engine run of the same stay at NewYork-Presbyterian Hospital, before the patient’s deductible and coinsurance and before the 2% sequestration reduction; the Original Medicare amount includes $2,412.85 of per-diem pass-through, which Medicare pays outside the claim. Field locations follow the 837I institutional claim implementation guide.
Further reading: