Example 01: Commercial Health Insurance

Patient is a different person than the Subscriber. Payer is commercial health insurance company.

SUBSCRIBER: Jane Smith

PATIENT ADDRESS: 236 N. Main St., Miami, Fl, 33413

TELEPHONE NUMBER: 305-555-1111

SEX: F

DOB: 05/01/43

EMPLOYER: ACME Inc.

GROUP #: 2222-SJ

KEY INSURANCE COMPANY ID #: JS00111223333

PATIENT: Ted Smith

PATIENT ADDRESS: 236 N. Main St., Miami, Fl, 33413

TELEPHONE NUMBER: 305-555-1111

SEX: M

DOB: 05/01/73

KEY INSURANCE COMPANY ID #: JS01111223333

DESTINATION PAYER: Key Insurance Company

PAYER ADDRESS: 3333 Ocean St. South Miami, FL 33000

PAYER ID: 999996666

SUBMITTER: Premier Billing Service

EDI#: TGJ23

CONTACT PERSON AND PHONE NUMBER: JERRY, 305-555-2222 ext. 231

RECEIVER: Key Insurance Company

EDI #:66783JJT

BILLING PROVIDER: Dr. Ben Kildare,

ADDRESS: 234 Seaway St, Miami, FL, 33111

NPI: 9876543210

TIN: 587654321

KEY INSURANCE COMPANY PROVIDER ID #: KA6663

Taxonomy Code: 203BF0100Y

PAY-TO PROVIDER: Kildare Associates,

PROVIDER ADDRESS: 2345 Ocean Blvd, Miami, Fl 33111

RENDERING PROVIDER: Dr. Ben Kildare

PATIENT ACCOUNT NUMBER: 2-646-3774

CASE: Patient has sore throat.

INITIAL VISIT: DOS=10/03/06. POS=Office

SERVICES: Office visit, intermediate service, established patient, throat culture.

CHARGES: Office first visit = $40.00, Lab test for strep = $15.00

FOLLOW-UP VISIT: DOS=10/10/06 POS=Office

Antibiotics didn’t work (pain continues).

SERVICES: Office visit, intermediate service, established patient, mono screening.

CHARGES: Follow-up visit = $35.00, lab test for mono = $10.00.

TOTAL CHARGES: $100.00.

ELECTRONIC ROUTE: Billing provider (sender), to VAN to Key Insurance Company (receiver). VAN claim identification number = 17312345600006351.

Transmission Explanation

HEADER

ST*837*0021*005010X222~

ST TRANSACTION SET HEADER

BHT*0019*00*244579*20061015*1023*CH~

BHT BEGINNING OF HIERARCHICAL TRANSACTION

1000A SUBMITTER

NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~

NM1 SUBMITTER NAME

PER*IC*JERRY*TE*3055552222*EX*231~

PER SUBMITTER EDI CONTACT INFORMATION

1000B RECEIVER

NM1*40*2*KEY INSURANCE COMPANY*****46*66783JJT~

NM1 RECEIVER NAME

2000A BILLING PROVIDER HL LOOP

HL*1**20*1~

HL - BILLING PROVIDER

PRV*BI*PXC*203BF0100Y~

PRV BILLING PROVIDER SPECIALTY INFORMATION

2010AA BILLING PROVIDER

NM1*85*2*BEN KILDARE SERVICE*****XX*9876543210~

NM1 BILLING PROVIDER NAME

N3*234 SEAWAY ST~

N3 BILLING PROVIDER ADDRESS

N4*MIAMI*FL*33111~

N4 BILLING PROVIDER LOCATION

REF*EI*587654321~

REF - BILLING PROVIDER TAX IDENTIFICATION

2010AB PAY-TO PROVIDER

NM1*87*2~

NM1 PAY-TO PROVIDER NAME

N3*2345 OCEAN BLVD~

N3 PAY-TO PROVIDER ADDRESS

N4*MIAMI*FL*33111~

N4 PAY-TO PROVIDER CITY

2000B SUBSCRIBER HL LOOP

HL*2*1*22*1~

HL - SUBSCRIBER

SBR*P**2222-SJ******CI~

SBR SUBSCRIBER INFORMATION

2010BA SUBSCRIBER

NM1*IL*1*SMITH*JANE****MI*JS00111223333~

NM1 SUBSCRIBER NAME

DMG*D8*19430501*F~

DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

2010BB PAYER

NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~

NM1 PAYER NAME

REF*G2*KA6663~

REF BILLING PROVIDER SECONDARY IDENTIFICATION

2000C PATIENT HL LOOP

HL*3*2*23*0~

HL - PATIENT

PAT*19~

PAT PATIENT INFORMATION

2010CA PATIENT

NM1*QC*1*SMITH*TED~

NM1 PATIENT NAME

N3*236 N MAIN ST~

N3 PATIENT ADDRESS

N4*MIAMI*FL*33413~

N4 PATIENT CITY/STATE/ZIP

DMG*D8*19730501*M~

DMG PATIENT DEMOGRAPHIC INFORMATION

2300 CLAIM

CLM*26463774*100***11:B:1*Y*A*Y*I~

CLM CLAIM LEVEL INFORMATION

REF*D9*17312345600006351~

REF CLAIM IDENTIFICATION NUMBER FOR CLEARING HOUSES (Added by C.H.)

HI*BK:0340*BF:V7389~

HI HEALTH CARE DIAGNOSIS CODES

2400 SERVICE LINE

LX*1~

LX SERVICE LINE COUNTER

SV1*HC:99213*40*UN*1***1~

SV1 PROFESSIONAL SERVICE

DTP*472*D8*20061003~

DTP DATE - SERVICE DATE(S)

2400 SERVICE LINE

LX*2~

LX SERVICE LINE COUNTER

SV1*HC:87070*15*UN*1***1~

SV1 PROFESSIONAL SERVICE

DTP*472*D8*20061003~

DTP DATE - SERVICE DATE(S)

2400 SERVICE LINE

LX*3~

LX SERVICE LINE COUNTER

SV1*HC:99214*35*UN*1***2~

SV1 PROFESSIONAL SERVICE

DTP*472*D8*20061010~

DTP DATE - SERVICE DATE(S)

2400 SERVICE LINE

LX*4~

LX SERVICE LINE COUNTER

SV1*HC:86663*10*UN*1***2~

SV1 PROFESSIONAL SERVICE

DTP*472*D8*20061010~

DTP DATE - SERVICE DATE(S)

TRAILER

SE*42*0021~

SE TRANSACTION SET TRAILER