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

Example 2: Encounter

Patient is the same person as the Subscriber. Payer is an HMO. Encounter is transmitted through a clearinghouse. Submitter is the billing provider, receiver is a payer.

SUBSCRIBER/PATIENT: Ted Smith

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

TELEPHONE NUMBER: 305-555-1111

SEX: M

DOB: 05/01/43

EMPLOYER: ACME Inc.

GROUP #: 12312-A

PAYER ID NUMBER: SSN

SSN: 000-22-1111

DESTINATION PAYER: Alliance Health and Life Insurance Company (AHLIC),

PAYER ADDRESS: 2345 West Grand Blvd, Detroit, MI 48202. ,

AHLIC #: 741234

SUBMITTER: Premier Billing Service

EDI#: TGJ23

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

RECEIVER: Alliance Health and Life Insurance Company (AHLIC),

EDI #: 66783JJT

BILLING PROVIDER: Dr. Ben Kildare,

ADDRESS: 234 Seaway St, Miami, FL, 33111

NPI: 9876543210

TIN: 587654321

Taxonomy Code: 203BF0100Y

PAY-TO PROVIDER: Kildare Associates,

PROVIDER ADDRESS: 2345 Ocean Blvd, Miami, Fl 33111

RENDERING PROVIDER: Dr. Ben Kildare/Family Practitioner

PATIENT ACCOUNT NUMBER: 2-646-2967

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 Clearinghouse to Alliance Health and Life Insurance Company (AHLIC);

Clearinghouse claim identification number = 17312345600006351.

Transmission Explanation

HEADER

ST*837*0021*005010X222~

ST TRANSACTION SET HEADER

BHT*0019*00*0123*20061015*1023*RP~

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*AHLIC*****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*0~

HL - SUBSCRIBER

SBR*P*18*12312-A******HM~

SBR SUBSCRIBER INFORMATION

2010BA SUBSCRIBER

NM1*IL*1*SMITH*TED****MI*000221111~

NM1 SUBSCRIBER NAME

N3*236 N MAIN ST~

N3 SUBSCRIBER ADDRESS

N4*MIAMI*FL*33413~

N4 SUBSCRIBER CITY

DMG*D8*19430501*M~

DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

2010BB SUBSCRIBER/PAYER

NM1*PR*2*ALLIANCE HEALTH AND LIFE INSURANCE*****PI*741234~

NM1 PAYER NAME

2300 CLAIM

CLM*26462967*100***11:B:1*Y*A*Y*I~

CLM CLAIM LEVEL INFORMATION

DTP*431*D8*19981003~

DTP DATE OF ONSET

REF*D9*17312345600006351~

REF CLEARING HOUSE CLAIM NUMBER (Added by CH)

HI*BK:0340*BF:V7389~

HI HEALTH CARE DIAGNOSIS CODES

2310C SERVICE LOCATION

NM1*77*2*KILDARE ASSOCIATES*****XX*5812345679~

NM1 SERVICE FACILITY LOCATION

N3*2345 OCEAN BLVD~

N3 SERVICE FACILITY ADDRESS

N4*MIAMI*FL*33111~

N4 SERVICE FACILITY CITY/STATE/ZIP

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:87072*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*41*0021~

SE TRANSACTION SET TRAILER