ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X222
Example 04: Medicare Secondary Payer (COB)
Patient and the Subscriber are the same person. The submitter is the provider. The provider previously sent the claim to the primary payer – Commerce. Payment received and the provider submitted the claim to the secondary payer, which is Medicare Part B. The claim was transmitted directly to Medicare by the submitter. Model used is provider to payer.
SUBSCRIBER/PATIENT: Wayne Medyum
ADDRESS: 1010 Thousand Oak Lane, Mayne, PA 17089
SEX: M
DOB: 1/10/1956
HEALTH INSURANCE CLAIM NUMBER: 102200221B1
DESTINATION PAYER: Medicare Part B Pennsylvania
PAYER ADDRESS: 5232 Mayne Avenue, Lyght, PA 17009
RECEIVER: Medicare Part B Pennsylvania
EDI #: 10234
BILLING PROVIDER/SENDER: Specialists
ADDRESS: 5 Map Court, Mayne, PA 17089
EDI # 110101
CONTACT PERSON AND PHONE NUMBER: Sue 8005558888
PATIENT ACCOUNT NUMBER: 101KEN6055
CASE: Lower leg pain
SERVICES: Office Visit– POS=Office
DATE OF SERVICE: 1/19/2005
CHARGE: $120
TOTAL CHARGES: $120
ELECTRONIC ROUTE: Billing provider (submitter) direct to Medicare Part B Pennsylvania
Transmission Explanation
HEADER
ST*837*0002*005010X222~
ST TRANSACTION SET HEADER
BHT*0019*00*000001142*20050214*115101*CH~
BHT BEGINNING OF HIERARCHICAL TRANSACTION
1000A SUBMITTER
NM1*41*2*SPECIALISTS*****46*1111111~
NM1 SUBMITTER
PER*IC*SUE*TE*8005558888~
PER SUBMITTER EDI CONTACT INFORMATION
1000B RECEIVER
NM1*40*2*MEDICARE PENNSYLVANIA*****46*10234~
NM1 RECEIVER NAME
2000A BILLING PROVIDER HL LOOP
HL*1**20*1~
HL BILLING PROVIDER
2010AA BILLING PROVIDER
NM1*85*2*SPECIALISTS*****XX*0100000090~
NM1 BILLING PROVIDER NAME
N3*5 MAP COURT~
N3 BILLING PROVIDER ADDRESS
N4*MAYNE*PA*17111~
N4 BILLING PROVIDER CITY/STATE/ZIP
REF*EI*890123456~
REF - BILLING PROVIDER TAX IDENTIFICATION
REF*1G*110101~
REF BILLING PROVIDER SECONDARY ID
2000B SUBSCRIBER HL LOOP
HL*2*1*22*0~
SBR*S*18*MEDICARE*12****MB~
SBR SUBSCRIBER INFORMATION
2010BA SUBSCRIBER
NM1*IL*1*MEDYUM*WAYNE*M***MI*102200221B1~
NM1 SUBSCRIBER NAME
N3*1010 THOUSAND OAK LANE~
N3 SUBSCRIBER ADDRESS
N4*MAYN*PA*17089~
N4 SUBSCRIBER CITY/STATE/ZIP
DMG*D8*19560110*M~
DMG SUBSCRIBER DEMOGRAPHIC INFORMATION
2010BB PAYER
NM1*PR*2*MEDICARE PENNSYLVANIA*****PI*10234~
NM1 PAYER NAME
N3*5232 MAYNE AVENUE~
N3 PAYER ADDRESS
N4*LYGHT*PA*17009~
N4 PAYER CITY/STATE/ZIP
2300 CLAIM
CLM*101KEN6055*120***11:B:1*Y*A*Y*Y*P~
CLM CLAIM LEVEL INFORMATION
HI*BK:71516*BF:71906~
HI HEALTH CARE DIAGNOSIS CODE(S)
2310A REFERRING PROVIDER
NM1*DN*1*BRYHT*LEE*T~
REF*1G*B01010~
REF REFERRING PROVIDER SECONDARY IDENTIFICATION
2310B RENDERING PROVIDER
NM1*82*1*HENZES*JACK****XX*9090909090~
PRV*PE*PXC*207X00000X~
PRV RENDERING PROVIDER INFORMATION
REF*G2*110102CCC~
REF RENDERING PROVIDER SECONDARY IDENTIFICATION
2320 OTHER SUBSCRIBER INFORMATION
SBR*P*01**COMMERCE*****CI~
SBR OTHER SUBSCRIBER INFORMATION
AMT*D*80~
AMT COORDINATION OF BENEFITS – PAYOR PAID AMOUNT
AMT*A8*15~
AMT COORDINATION OF BENEFITS – PATIENT RESPONSIBILITY
OI**Y*P**Y~
OI OTHER INSURANCE COVERAGE INFORMATION
2330A OTHER SUBSCRIBER NAME
NM1*IL*1*MEDYUM*CAROL****MI*COM188-404777~
NM1 OTHER SUBSCRIBER NAME
N3*PO BOX 45~
N3 OTHER SUBSCIBER ADDRESS
N4*MAYN*PA*17089~
N4 OTHER SUBSCRIBER CITY/STATE/ZIP CODE
2330B OTHER SUBSCRIBER/PAYER
NM1*PR*2*COMMERCE*****PI*59999~
NM1 OTHER PAYER NAME
2400 SERVICE LINE
LX*1~
LX SERVICE LINE COUNTER
SV1*HC:99203:25*120*UN*1***1:2~
SV1 PROFESSIONAL SERVICE
DTP*472*D8*20050119~
DTP DATE - SERVICE DATE
2420 LINE ADJUDICATION INFORMATION
SVD*59999*80*HC:99203:25**1~
SVD LINE ADJUDICATION INFORMATION
CAS*CO*42*25~
CAS LINE ADJUSTMENT
CAS*PR*2*15~
CAS LINE ADJUSTMENT
DTP*573*D8*20050128~
DTP LINE ADJUDICATION DATE
TRAILER
SE*43*000000002~
SE TRANSACTION SET TRAILER