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

Example 4: Medicare Secondary Payer (COB)

Patient and the Subscriber are the same person. The submitter is the provider. The provider previously sent the claim to the primary payer – Commerce. Payment received and the provider submitted the claim to the secondary payer, which is Medicare Part B. The claim was transmitted directly to Medicare by the submitter. Model used is provider to payer.

SUBSCRIBER/PATIENT: Wayne Medyum

ADDRESS: 1010 Thousand Oak Lane, Mayne, PA 17089

SEX: M

DOB: 1/10/1956

HEALTH INSURANCE CLAIM NUMBER: 102200221B1

DESTINATION PAYER: Medicare Part B Pennsylvania

PAYER ADDRESS: 5232 Mayne Avenue, Lyght, PA 17009

RECEIVER: Medicare Part B Pennsylvania

EDI #: 10234

BILLING PROVIDER/SENDER: Specialists

ADDRESS: 5 Map Court, Mayne, PA 17089

EDI # 110101

CONTACT PERSON AND PHONE NUMBER: Sue 8005558888

PATIENT ACCOUNT NUMBER: 101KEN6055

CASE: Lower leg pain

SERVICES: Office Visit– POS=Office

DATE OF SERVICE: 1/19/2005

CHARGE: $120

TOTAL CHARGES: $120

ELECTRONIC ROUTE: Billing provider (submitter) direct to Medicare Part B Pennsylvania

Transmission Explanation

HEADER

ST*837*0002*005010X222~

ST TRANSACTION SET HEADER

BHT*0019*00*000001142*20050214*115101*CH~

BHT BEGINNING OF HIERARCHICAL TRANSACTION

1000A SUBMITTER

NM1*41*2*SPECIALISTS*****46*1111111~

NM1 SUBMITTER

PER*IC*SUE*TE*8005558888~

PER SUBMITTER EDI CONTACT INFORMATION

1000B RECEIVER

NM1*40*2*MEDICARE PENNSYLVANIA*****46*10234~

NM1 RECEIVER NAME

2000A BILLING PROVIDER HL LOOP

HL*1**20*1~

HL BILLING PROVIDER

2010AA BILLING PROVIDER

NM1*85*2*SPECIALISTS*****XX*0100000090~

NM1 BILLING PROVIDER NAME

N3*5 MAP COURT~

N3 BILLING PROVIDER ADDRESS

N4*MAYNE*PA*17111~

N4 BILLING PROVIDER CITY/STATE/ZIP

REF*EI*890123456~

REF - BILLING PROVIDER TAX IDENTIFICATION

REF*1G*110101~

REF BILLING PROVIDER SECONDARY ID

2000B SUBSCRIBER HL LOOP

HL*2*1*22*0~

SBR*S*18*MEDICARE*12****MB~

SBR SUBSCRIBER INFORMATION

2010BA SUBSCRIBER

NM1*IL*1*MEDYUM*WAYNE*M***MI*102200221B1~

NM1 SUBSCRIBER NAME

N3*1010 THOUSAND OAK LANE~

N3 SUBSCRIBER ADDRESS

N4*MAYN*PA*17089~

N4 SUBSCRIBER CITY/STATE/ZIP

DMG*D8*19560110*M~

DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

2010BB PAYER

NM1*PR*2*MEDICARE PENNSYLVANIA*****PI*10234~

NM1 PAYER NAME

N3*5232 MAYNE AVENUE~

N3 PAYER ADDRESS

N4*LYGHT*PA*17009~

N4 PAYER CITY/STATE/ZIP

2300 CLAIM

CLM*101KEN6055*120***11:B:1*Y*A*Y*Y*P~

CLM CLAIM LEVEL INFORMATION

HI*BK:71516*BF:71906~

HI HEALTH CARE DIAGNOSIS CODE(S)

2310A REFERRING PROVIDER

NM1*DN*1*BRYHT*LEE*T~

REF*1G*B01010~

REF REFERRING PROVIDER SECONDARY IDENTIFICATION

2310B RENDERING PROVIDER

NM1*82*1*HENZES*JACK****XX*9090909090~

PRV*PE*PXC*207X00000X~

PRV RENDERING PROVIDER INFORMATION

REF*G2*110102CCC~

REF RENDERING PROVIDER SECONDARY IDENTIFICATION

2320 OTHER SUBSCRIBER INFORMATION

SBR*P*01**COMMERCE*****CI~

SBR OTHER SUBSCRIBER INFORMATION

AMT*D*80~

AMT COORDINATION OF BENEFITS – PAYOR PAID AMOUNT

AMT*A8*15~

AMT COORDINATION OF BENEFITS – PATIENT RESPONSIBILITY

OI**Y*P**Y~

OI OTHER INSURANCE COVERAGE INFORMATION

2330A OTHER SUBSCRIBER NAME

NM1*IL*1*MEDYUM*CAROL****MI*COM188-404777~

NM1 OTHER SUBSCRIBER NAME

N3*PO BOX 45~

N3 OTHER SUBSCIBER ADDRESS

N4*MAYN*PA*17089~

N4 OTHER SUBSCRIBER CITY/STATE/ZIP CODE

2330B OTHER SUBSCRIBER/PAYER

NM1*PR*2*COMMERCE*****PI*59999~

NM1 OTHER PAYER NAME

2400 SERVICE LINE

LX*1~

LX SERVICE LINE COUNTER

SV1*HC:99203:25*120*UN*1***1:2~

SV1 PROFESSIONAL SERVICE

DTP*472*D8*20050119~

DTP DATE - SERVICE DATE

2420 LINE ADJUDICATION INFORMATION

SVD*59999*80*HC:99203:25**1~

SVD LINE ADJUDICATION INFORMATION

CAS*CO*42*25~

CAS LINE ADJUSTMENT

CAS*PR*2*15~

CAS LINE ADJUSTMENT

DTP*573*D8*20050128~

DTP LINE ADJUDICATION DATE

TRAILER

SE*43*000000002~

SE TRANSACTION SET TRAILER