Section title: X12 EDI Examples
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ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X222

Example 09: Anesthesia

Patient is the same as the subscriber. Payer is Medicare. Encounter is billed directly to Medicare.

SUBSCRIBER/PATIENT: Margaret Jones

ADDRESS: 123 Rainbow Road, Nashville, TN 37232

TELEPHONE: 615-555-1212

SEX: F

DOB: 03/03/1974

EMPLOYER: ACME Inc.

SUBSCRIBER #: 123456789A

SECONDARY COVERAGE

DESTINATION PAYER: ABC Payer

PAYER ADDRESS: P.O. Box 1465, Nashville, TN, 37232

PAYER ORGANIZATION ID: 05440

RECEIVER: ABC Payer

EDI #: 05440

BILLING PROVIDER/SENDER: Provider Medical Group

ADDRESS: 1234 West End Ave, Nashville, TN, 37232

NPI#: 2366554859

TIN: 756473826

EDI #: N305

CONTACT PERSON AND PHONE NUMBER: Nina, 615-555-1212 ext.911

RENDERING PROVIDER: Dr. Jacob E. Townsend/Anesthesiologist

NPI: 5678912345

MEDICARE PROVIDER ID#: 9741234

PLACE OF SERVICE: Provider OP Hospital

PLACE OF SERVICE ADDRESS: 345 Main Drive, Nashville, TN, 37232

PLACE OF SERVICE ID#: 43294867

PATIENT ACCOUNT NUMBER: 543211230

CASE: Laser Eye Surgery.

VISIT: DOS=1/12/2005 POS=Outpatient Hospital

SERVICES: Anesthesia for the Laser Eye Surgery

CHARGES: Anesthesia, 61 minutes = $827.00

CONCURRENCY: 2 cases

PHYSICAL STATUS: Normal

PATIENT CONTROL #: 153829140

MEDICAL RECORD ID #: 006653794

TOTAL CHARGES: $827.00

ELECTRONIC ROUTE: Billing Provider (sender) to ABC PAYER direct

Transmission Explanation

HEADER

ST*837*0001*005010X222~

ST TRANSACTION SET HEADER

BHT*0019*00*0123*20050117*1023*CH~

BHT BEGINNING OF HIERARCHICAL TRANSACTION

1000A SUBMITTER

NM1*41*2*PROVIDER MEDICAL GROUP*****46*N305~

NM1 SUBMITTER

PER*IC*NINA*TE*6155551212*EX*911~

PER SUBMITTER EDI CONTACT INFORMATION

1000B RECEIVER

NM1*40*2*ABC PAYER*****46*05440~

NM1 RECEIVER NAME

2000A BILLING PROVIDER HL LOOP

HL*1**20*1~

HL - BILLING PROVIDER

2010AA BILLING PROVIDER

NM1*85*2*PROVIDER MEDICAL GROUP*****XX*2366554859~

NM1 BILLING PROVIDER NAME

N3*1234 WEST END AVE~

N3 BILLING PROVIDER ADDRESS

N4*NASHVILLE*TN*37232~

N4 BILLING PROVIDER CITY/STATE/ZIP

REF*EI*756473826~

REF BILLING PROIVDER TAX IDENTIFIER

2000B SUBSCRIBER HL LOOP

HL*2*1*22*0~

HL - SUBSCRIBER

SBR*P*18*******MB~

SBR SUBSCRIBER INFORMATION

2010BA SUBSCRIBER

NM1*IL*1*JONES*MARGARET****MI*123456789A~

NM1 SUBSCRIBER NAME

N3*123 RAINBOW ROAD~

N3 SUBSCRIBER STREET ADDRESS

N4*NASHVILLE*TN*37232~

N4 SUBSCRIBER CITY/STATE/ZIP

DMG*D8*19740303*F~

DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

2010BB SUBSCRIBER / PAYER

NM1*PR*2*ABC PAYER*****PI*05440~

NM1 PAYER NAME

2300 CLAIM

CLM*153829140*827**22:B:1*Y*A*Y*Y~

CLM CLAIM LEVEL INFORMATION

HI*BK:36616~

HI HEALTH CARE DIAGNOSIS CODES

2310B RENDERING PROVIDER

NM1*82*1*TOWNSEND*JACOB*E***XX*5678912345~

NM1 RENDERING PROVIDER NAME

PRV*PE*PXC*207L00000X~

PRV RENDERING PROVIDER TAXONOMY INFORMATION

REF*G2*9741234~

REF RENDERING PROVIDER SECONDARY IDENTIFICATION

2310C SERVICE FACILITY LOCATION

NM1*77*2*PROVIDER OP HOSP*****XX*432198765~

NM1 SERVICE FACILITY LOCATION

N3*345 MAIN DRIVE~

N3 SERVICE FACILITY LOCATION

N4*NASHVILLE*TN*37232~

N4 SERVICE FACILITY LOCATION CITY/STATE/ZIP

2400 SERVICE LINE

LX*1~

LX SERVICE LINE COUNTER

SV1*HC:00142:QK:QS:P1*827*MJ*61***1~

SV1 PROFESSIONAL SERVICE

DTP*472*D8*20050112~

DTP DATE - SERVICE DATE

TRAILER

SE*29*0001~

SE TRANSACTION SET TRAILER