ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X222
Example 11: PPO Repriced Claim
Repriced claim being transmitted from a Regional PPO (Preferred Provider Organization) to a commercial health insurance company. The patient is the same person as the subscriber. In this situation, the provider has sent the claim to a clearinghouse, which then forwarded the claim to the repricer; the claim has been repriced and is now being forwarded to the appropriate payer for payment.
SUBSCRIBER/PATIENT: Diamond D. Ring
ADDRESS: 123 Example Drive, Indianapolis, IN 462290000
SEX: F
DATE OF BIRTH: 12/29/1940
EMPLOYER: COMPANY, INC.
GROUP NUMBER: 123XYZ
MEMBER ID: 00124A089
PATIENT ACCOUNT NUMBER: ABC123-RI
SUBMITTER: Regional PPO Network
SUBMITTER ID: 123456789
RECEIVER: Extra Healthy Insurance
RECEIVER ID: 112244
DESTINATION PAYER: Extra Healthy Insurance
PAYER ID NUMBER: 12345
BILLING PROVIDER: HAPPY DOCTORS GROUP PRACTICE
ADDRESS: P O BOX 123, Fort Wayne, IN 462540000
NATIONAL PROVIDER ID (NPI): 1234567890
TAX IDENTIFICATION NUMBER (TIN): 555-51-2345
RENDERING PROVIDER: John Doe
NATIONAL PROVIDER ID (NPI): 9988776655
RENDERING PROVIDER: Susan B. Anthony
NATIONAL PROVIDER ID (NPI): 1122334455
TOTAL CLAIM CHARGES: $28.75
TOTAL CLAIM REPRICED AMOUNT: $26.75
TOTAL CLAIM SAVINGS AMOUNT: $2.00
SERVICE LINE 1 REPRICING INFORMATION:
TOTAL SERVICE LINE CHARGES: $25.00
TOTAL REPRICED AMOUNT: $23.75
SAVINGS AMOUNT: $1.25
TIN FOR THE REPRICING ORGANIZATION: 908231234
DATE OF SERVICE: 05/14/05
SERVICE LINE 2 REPRICING INFORMATION:
TOTAL SERVICE LINE CHARGES: $3.75
TOTAL REPRICED AMOUNT: $3
SAVINGS AMOUNT: $.75
TIN FOR THE REPRICING ORGANIZATION: 908231234
DATE OF SERVICE: 05/14/05
Transmission Explanation
HEADER
ST*837*1002*005010X222A1~
ST TRANSACTION SET HEADER
BHT*0019*00*1002*20050620*09460000*CH~
BHT BEGINNING OF HIERARCHICAL TRANSACTION
1000A SUBMITTER
NM1*41*2*REGIONAL PPO NETWORK*****46*123456789~
NM1 SUBMITTER
PER*IC*SUBMITTER CONTACT INFO*TE*8001231234~
PER SUBMITTER EDI CONTACT INFORMATION
1000B RECEIVER
NM1*40*2*EXTRA HEALTHY INSURANCE*****46*112244~
NM1 RECEIVER NAME
2000A BILLING PROVIDER
HL*1**20*1~
HL BILLING PROVIDER HIERARCHICAL LEVEL
2010AA BILLING PROVIDER NAME
NM1*85*2*HAPPY DOCTORS GROUP PRACTICE*****XX*1234567890~
NM1 BILLING PROVIDER NAME INCLUDING NATIONAL PROVIDER ID
N3*P O BOX 123~
N3 BILLING PROVIDER ADDRESS
N4*FORT WAYNE*IN*462540000~
N4 BILLING PROVIDER LOCATION
REF*EI*555512345~
REF BILLING PROVIDER TAX IDENTIFICATION NUMBER
PER*IC*SUE BILLINGSWORTH*TE*8881231234~
PER BILLING PROVIDER CONTACT INFORMATION
2000B SUBSCRIBER HL LOOP
HL*2*1*22*0~
HL SUBSCRIBER HIERARCHICAL LEVEL
SBR*P*18*123XYZ******CI~
SBR SUBSCRIBER INFORMATION
2010BA SUBSCRIBER NAME LOOP
NM1*IL*1*RING*DIAMOND*D***MI*00124A089~
NM1 SUBSCRIBER NAME
N3*123 EXAMPLE DRIVE~
N3 SUBSCRIBER ADDRESS
N4*INDIANAPOLIS*IN*462290000~
N4 SUBSCRIBER LOCATION
DMG*D8*19401229*F~
DMG SUBSCRIBER DEMOGRAPHIC INFORMATION
2010BB PAYER NAME LOOP
NM1*PR*2*EXTRA HEALTHY INSURANCE*****PI*12345~
NM1 PAYER NAME
2300 CLAIM
CLM*ABC123-RI*28.75***11:B:1*Y*A*Y*Y*P~
CLM CLAIM LEVEL INFORMATION
REF*9A*0902352342~
REF REPRICED CLAIM NUMBER
REF*D9*061505501749388~
REF CLEARING HOUSE CLAIM NUMBER (ASSIGNED BY THE CLEARING HOUSE WHEN TRANSMITTING TO THE REPRICER)
REF*9F*REFNBR~
REF REFERRAL NUMBER
HI*BK:496*BF:25000~
HI HEALTH CARE DIAGNOSIS CODES
HCP*03*26.75*2*908231234~
HCP HEALTH CARE PRICING - REPRICING INFORMATION
2310A REFERRING PROVIDER
NM1*DN*1*DOE*JOHN****XX*9988776655~
NM1 REFERRING PROVIDER
2310B RENDERING PROVIDER
NM1*82*1*ANTHONY*SUSAN*B***XX*1122334455~
NM1 RENDERING PROVIDER
2310D SERVICE FACILITY LOCATION
NM1*77*2*HAPPY DOCTORS GROUP~
NM1 SERVICE FACILITY LOCATION
N3*123 FEEL GOOD ROAD~
N3 FACILITY ADDRESS
N4*WASHINGTON*IN*475010000~
N4 FACILITY LOCATION
2400 SERVICE LINE
LX*1~
LX SERVICE LINE COUNTER
SV1*HC:E0570:RR*25*UN*1***1:2~
SV1 PROFESSIONAL SERVICE
DTP*472*D8*20050514~
DTP DATE - SERVICE DATES
HCP*03*23.75*1.25*908231234~
HCP HEALTH CARE PRICING - REPRICING INFORMATION
2400 SERVICE LINE
LX*2~
LX SERVICE LINE COUNTER
SV1*HC:A7003:NU*3.75*UN*1***1~
SV1 PROFESSIONAL SERVICE
DTP*472*D8*20050514~
DTP DATE - SERVICE DATES
HCP*03*3*.75*908231234~
HCP HEALTH CARE PRICING - REPRICING INFORMATION
TRAILER
SE*38*1002~
SE TRANSACTION SET TRAILER