Definition
Healthcare Claim
A healthcare claim is the bill a provider or pharmacy submits to a health plan to request payment for care, listing the patient, the treating and billing providers, diagnoses, services delivered and charges.
2 min readReviewed September 14, 2026
Also known as: Medical claim, Health insurance claim, Professional claim, Institutional claim, Claims data
Key facts
- Medical claim standard
- ASC X12 837, Version 5010, adopted under HIPAA
- Pharmacy claim standard
- NCPDP Telecommunication Standard Version D.0
- Paper forms
- CMS-1500 for professional claims; UB-04 (CMS-1450) for institutional claims
- HIPAA transaction rules
- 45 CFR Part 162
- Medicare filing deadline
- Generally within 12 months of the date of service
What is a healthcare claim?
A claim is the core financial transaction in health care. It carries patient and insurance identifiers, the billing and rendering providers identified by National Provider Identifier (NPI), diagnosis codes, procedure or revenue codes, dates and place of service, and charges. Drug lines can also carry a National Drug Code (NDC).
Under HIPAA, electronic claims must use the adopted standard formats, and Medicare requires electronic submission from most providers. Paper claims remain for small providers and a few special situations.
Types of healthcare claims
Claims are grouped by who bills and what is billed:
- Professional claims (837P or CMS-1500): physicians, nurse practitioners, therapists and other clinicians, coded with CPT and HCPCS.
- Institutional claims (837I or UB-04): hospitals, skilled nursing facilities, home health agencies and hospices, using revenue codes and, for inpatient stays, ICD-10-PCS procedure codes.
- Pharmacy claims (NCPDP D.0): prescriptions dispensed at retail, mail and specialty pharmacies, usually adjudicated in real time.
- Dental claims (837D): dental services coded with CDT codes.
- Encounter records: submitted by managed care plans to report services paid under capitation, in claim format but without a fee-for-service payment.
Why claims matter
Claims are the raw material for most real-world healthcare analytics. Medicare Part B and Part D public use files, prescriber targeting lists, referral networks and procedure volume estimates are built by aggregating claims by NPI, code and time period.
Claims also link datasets. The NPI on a claim joins to provider directories, the NDC to drug product and pricing files, and diagnosis and procedure codes to clinical classifications, which is how analysts connect prescribing, procedures and facilities for the same provider.
Limitations of claims data
Claims show what was billed and paid, not clinical results. Diagnosis codes reflect billing requirements as well as clinical reality, and services not billed to insurance, such as cash-pay care, are missing. Data arrive with a lag while late claims and adjustments come in, and commercial claims datasets vary in which payers, regions and settings they capture.