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

Example 3: Coordination of Benefits (COB)

Coordination of benefits; patient is not the subscriber; payers are commercial health insurance companies. Patient and subscriber have same primary policy number. Claim submitted to primary insurer with information pertaining to the secondary payer.

SUBSCRIBER FOR PAYER A: Jane Smith

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

TELEPHONE NUMBER: 305-555-1111

SEX: F

DOB: 05/01/43

EMPLOYER: Acme, Inc.

PAYER A ID NUMBER: JS00111223333

SSN: 111-22-3333

SUBSCRIBER FOR PAYER B: Jack Smith

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

TELEPHONE NUMBER: 305-555-1111

SEX: M

DOB: 10/22/43

EMPLOYER: Telecom of Florida

PAYER B ID NUMBER: T55TY666

SSN: 222-33-4444

PATIENT: Ted Smith

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

TELEPHONE NUMBER: 305-555-1111

SEX: M

DOB: 05/01/73

PAYER A ID NUMBER: JS01111223333

PAYER B ID NUMBER: T55TY666-01

SSN: SSN: 000-22-1111

DESTINATION PAYER A: Key Insurance Company

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

PAYER A ID NUMBER: (TIN) 999996666

RECEIVER FOR PAYER A: XYZ REPRICER

EDI #: 66783JJT

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

EDI #: 66783JJT

DESTINATION PAYER B (RECEIVER): Great Prairies Health

PAYER B ADDRESS: 4456 South Shore Blvd., Chicago, IL 44444

PAYER B ID NUMBER: 567890

EDI #: 567890

BILLING PROVIDER/SENDER: Dr. Ben Kildare

ADDRESS: 234 Seaway St, Miami, FL, 33111

PAYER A ID NUMBER: KA6663

PAYER B ID NUMBER: 88877

TIN: 999996666

EDI # FOR RECEIVER A: TGJ23

EDI # FOR PAYER B: 12EEER000TY

PAY-TO PROVIDER: Kildare Associates,

ADDRESS: 2345 Ocean Blvd, Miami, Fl 33111

PAYER A ID NUMBER: 99878ABA

PAYER B ID NUMBER: EX7777

TIN: 581234567

RENDERING PROVIDER: Dr. Ben Kildare

PAYER A ID NUMBER: KA6663

PAYER B ID NUMBER: 88877

TIN: 999996666

PATIENT ACCOUNT NUMBER: 26407789

CASE: Patient came to office for routine hyperlipidemia check. DOS=10/03/05,

POS=Office; Patient also complained of hay fever and heart burn.

SERVICES RENDERED: Patient received injection for hyperlipidemia and hay fever.

CHARGES: Patient was charged for office visit ($43.00), and two injections ($15.00 and $21.04).

ELECTRONIC PATH: The billing provider (sender) transmits the claim to Payer A (receiver) (Example 3.A) who adjudicates the claim. Payer A transmits back an 835 to the billing provider.The billing provider then submits a second claim to Payer B (receiver) (Example 3.B).