ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X222
Example 05: Ambulance
Patient is the same person as the subscriber.The provider type is ambulance. The payer is medicare. The submitter is the same as the provider. The receiver is medicare.
SUBSCRIBER/PATIENT: Sarah Jones
ADDRESS: 1129 Reindeer Road, Carr, CO 80612
TELEPHONE NUMBER: 305-555-1111
SEX: F
DOB: 07/29/1963
SUBSCRIBER ID: 012345678A
DESTINATION PAYER: Medicare Part B
PAYER ADDRESS: P. O. Box 3543, Baltimore, MD. 666013543
RECEIVER: Medicare
EDI #: 123245
BILLING PROVIDER/SENDER: AAA Ambulance Service
ADDRESS: 12202 Airport Way, Broomfield, CO 80221-0021
TIN: 376985369
NPI: 2366554859
CONTACT PERSON AND PHONE NUMBER: Lisa Smith, 303-775-2536
PATIENT ACCOUNT NUMBER: 05-1068
DIAGNOSIS: 8628, E8888, 9592, 8540
SERVICES: A0427 - Ambulance Transport $700.00
A0425 - Mileage $8.20
A0422 - Oxygen $46.00
A0382 - BLS Disposable Supplies $12.30
TOTAL CHARGES: $766.50
MISCELLANEOUS: Two patients were transported.
ELECTRONIC ROUTE: Billing Provider (Sender) to Medicare
Transmission Explanation
HEADER
ST*837*000017712*005010X222~
ST TRANSACTION SET HEADER
BHT*0019*00*000017712*20050208*1112*CH~
BHT BEGINNING OF HIERARCHICAL TRANSACTION
1000A SUBMITTER
NM1*41*2*AAA AMBULANCE SERVICE*****46*376985369~
NM1 SUBMITTER NAME
PER*IC*LISA SMITH*TE*3037752536~
PER SUBMITTER EDI CONTACT INFORMATION
1000B RECEIVER
NM1*40*2*MEDICARE B*****46*123245~
NM1 RECEIVER NAME
2000A BILLING PROVIDER HL LOOP
HL*1**20*1~
HL - BILLING PROVIDER
2010AA BILLING PROVIDER
PRV*BI*PXC*3416L0300X~
PRV BILLING PROVIDER SPECIALTY
NM1*85*2*AAA AMBULANCE SERVICE*****XX*2366554859~
NM1 BILLING PROVIDER NAME
N3*12202 AIRPORT WAY~
N3 BILLING PROVIDER ADDRESS
N4*BROOMFIELD*CO*800210021~
N4 BILLING PROVIDER LOCATION
REF*EI*376985369~
REF - BILLING PROVIDER TAX IDENTIFICATION
2000B SUBSCRIBER HL LOOP
HL*2*1*22*0~
HL - SUBSCRIBER
SBR*P*18*******MB~
SBR SUBSCRIBER INFORMATION
2010BA SUBSCRIBER
NM1*IL*1*JONES*SARAH*A***MI*012345678A~
NM1 SUBSCRIBER NAME
N3*1129 REINDEER ROAD~
N3 SUBSCRIBER ADDRESS
N4*CARR*CO*80612~
N4 SUBSCRIBER CITY, STATE, ZIP CODE
DMG*D8*19630729*F~
DMG SUBSCRIBER DEMOGRAPHIC INFORMATION
2010BB PAYER
NM1*PR*2*MEDICARE PART B*****PI*123245~
NM1 PAYER NAME
N3*PO BOX 3543~
N3 PAYER ADDRESS
N4*BALTIMORE*MD*666013543~
N4 LOCATION
2300 CLAIM
CLM*051068*766.50**41:B:1*Y*A*Y*Y*P*OA~
CLM CLAIM LEVEL INFORMATION
DTP*439*D8*20050208~
DTP DATE ACCIDENT
CR1*LB*275**A*DH*21****PATIENT IMOBILIZED~
CR1 AMBULANCE TRANSPORT INFORMATION
CRC*07*Y*04*06*09~
CRC AMBULANCE CERTIFICATION
CRC*07*N*05*07*08~
CRC AMBULANCE CERTIFICATION
HI*BK:8628*BF:E8888*BF:9592*BF:8540~
HI HEALTH CARE DIAGNOSIS
2310E AMBULANCES PICK-UP LOCATION
NM1*PW*2~
NM1 PICK UP LOCATION
N3*1129 REINDEER ROAD~
N3 PICK UP ADDRESS
N4*CARR*CO*80612~
N4 PICK UP LOCATION
2310F AMBULANCE DROP-OFF LOCATION
NM1*45*2~
NM1 DROP OFF LOCATION
N3*10005 BANNOCK ST~
N3 - DROP OFF ADDRESS
N4*CHEYENNE*WY*82009~
N4 - DROP OFF LOCATION
2400 SERVICE LINE
LX*1~
LX SERVICE LINE NUMBER
SV1*HC:A0427:RH*700*UN*1***1:2:3:4**Y~
SV1 - PROFESSIONAL SERVICE
DTP*472*D8*20050208~
DTP DATE - SERVICE DATE
QTY*PT*2~
QTY - AMBULANCE PATIENT COUNT
REF*6R*1001~
REF - LINE ITEM CONTROL NUMBER
NTE*ADD*CARDIAC EMERGENCY~
NTE - LINE NOTE
LX*2~
LX SERVICE LINE NUMBER
SV1*HC:A0425:RH*8.20*UN*21***1:2:3:4**Y~
SV1 - PROFESSIONAL SERVICE
DTP*472*D8*20050208~
DTP - SERVICE DATE
QTY*PT*2~
QTY - AMBULANCE PATIENT COUNT
REF*6R*1002~
REF - LINE CONTROL NUMBER
LX*3~
LX - SERVICE LINE NUMBER
SV1*HC:A0422:RH*46*UN*1***1:2:3:4**Y~
SV1 - PROFESSIONAL SERVICE
DTP*472*D8*20050208~
DTP - SERVICE DATE
REF*6R*1003~
REF - LINE CONTROL NUMBER
LX*4~
LX - SERVICE LINE NUMBER
SV1*HC:A0382:RH*12.30*UN*1***1:2:3:4**Y~
SV1 - PROFESSIONAL SERVICE
DTP*472*D8*20050208~
DTP - SERVICE DATE
REF*6R*1004~
REF - LINE CONTROL NUMBER
TRAILER
SE*52*000017712~
SE TRANSACTION SET TRAILER