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

Example 5: Ambulance

Patient is the same person as the subscriber.The provider type is ambulance. The payer is medicare. The submitter is the same as the provider. The receiver is medicare.

SUBSCRIBER/PATIENT: Sarah Jones

ADDRESS: 1129 Reindeer Road, Carr, CO 80612

TELEPHONE NUMBER: 305-555-1111

SEX: F

DOB: 07/29/1963

SUBSCRIBER ID: 012345678A

DESTINATION PAYER: Medicare Part B

PAYER ADDRESS: P. O. Box 3543, Baltimore, MD. 666013543

RECEIVER: Medicare

EDI #: 123245

BILLING PROVIDER/SENDER: AAA Ambulance Service

ADDRESS: 12202 Airport Way, Broomfield, CO 80221-0021

TIN: 376985369

NPI: 2366554859

CONTACT PERSON AND PHONE NUMBER: Lisa Smith, 303-775-2536

PATIENT ACCOUNT NUMBER: 05-1068

DIAGNOSIS: 8628, E8888, 9592, 8540

SERVICES: A0427 - Ambulance Transport $700.00

A0425 - Mileage $8.20

A0422 - Oxygen $46.00

A0382 - BLS Disposable Supplies $12.30

TOTAL CHARGES: $766.50

MISCELLANEOUS: Two patients were transported.

ELECTRONIC ROUTE: Billing Provider (Sender) to Medicare

Transmission Explanation

HEADER

ST*837*000017712*005010X222~

ST TRANSACTION SET HEADER

BHT*0019*00*000017712*20050208*1112*CH~

BHT BEGINNING OF HIERARCHICAL TRANSACTION

1000A SUBMITTER

NM1*41*2*AAA AMBULANCE SERVICE*****46*376985369~

NM1 SUBMITTER NAME

PER*IC*LISA SMITH*TE*3037752536~

PER SUBMITTER EDI CONTACT INFORMATION

1000B RECEIVER

NM1*40*2*MEDICARE B*****46*123245~

NM1 RECEIVER NAME

2000A BILLING PROVIDER HL LOOP

HL*1**20*1~

HL - BILLING PROVIDER

2010AA BILLING PROVIDER

PRV*BI*PXC*3416L0300X~

PRV BILLING PROVIDER SPECIALTY

NM1*85*2*AAA AMBULANCE SERVICE*****XX*2366554859~

NM1 BILLING PROVIDER NAME

N3*12202 AIRPORT WAY~

N3 BILLING PROVIDER ADDRESS

N4*BROOMFIELD*CO*800210021~

N4 BILLING PROVIDER LOCATION

REF*EI*376985369~

REF - BILLING PROVIDER TAX IDENTIFICATION

2000B SUBSCRIBER HL LOOP

HL*2*1*22*0~

HL - SUBSCRIBER

SBR*P*18*******MB~

SBR SUBSCRIBER INFORMATION

2010BA SUBSCRIBER

NM1*IL*1*JONES*SARAH*A***MI*012345678A~

NM1 SUBSCRIBER NAME

N3*1129 REINDEER ROAD~

N3 SUBSCRIBER ADDRESS

N4*CARR*CO*80612~

N4 SUBSCRIBER CITY, STATE, ZIP CODE

DMG*D8*19630729*F~

DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

2010BB PAYER

NM1*PR*2*MEDICARE PART B*****PI*123245~

NM1 PAYER NAME

N3*PO BOX 3543~

N3 PAYER ADDRESS

N4*BALTIMORE*MD*666013543~

N4 LOCATION

2300 CLAIM

CLM*051068*766.50**41:B:1*Y*A*Y*Y*P*OA~

CLM CLAIM LEVEL INFORMATION

DTP*439*D8*20050208~

DTP DATE ACCIDENT

CR1*LB*275**A*DH*21****PATIENT IMOBILIZED~

CR1 AMBULANCE TRANSPORT INFORMATION

CRC*07*Y*04*06*09~

CRC AMBULANCE CERTIFICATION

CRC*07*N*05*07*08~

CRC AMBULANCE CERTIFICATION

HI*BK:8628*BF:E8888*BF:9592*BF:8540~

HI HEALTH CARE DIAGNOSIS

2310E AMBULANCES PICK-UP LOCATION

NM1*PW*2~

NM1 PICK UP LOCATION

N3*1129 REINDEER ROAD~

N3 PICK UP ADDRESS

N4*CARR*CO*80612~

N4 PICK UP LOCATION

2310F AMBULANCE DROP-OFF LOCATION

NM1*45*2~

NM1 DROP OFF LOCATION

N3*10005 BANNOCK ST~

N3 - DROP OFF ADDRESS

N4*CHEYENNE*WY*82009~

N4 - DROP OFF LOCATION

2400 SERVICE LINE

LX*1~

LX SERVICE LINE NUMBER

SV1*HC:A0427:RH*700*UN*1***1:2:3:4**Y~

SV1 - PROFESSIONAL SERVICE

DTP*472*D8*20050208~

DTP DATE - SERVICE DATE

QTY*PT*2~

QTY - AMBULANCE PATIENT COUNT

REF*6R*1001~

REF - LINE ITEM CONTROL NUMBER

NTE*ADD*CARDIAC EMERGENCY~

NTE - LINE NOTE

LX*2~

LX SERVICE LINE NUMBER

SV1*HC:A0425:RH*8.20*UN*21***1:2:3:4**Y~

SV1 - PROFESSIONAL SERVICE

DTP*472*D8*20050208~

DTP - SERVICE DATE

QTY*PT*2~

QTY - AMBULANCE PATIENT COUNT

REF*6R*1002~

REF - LINE CONTROL NUMBER

LX*3~

LX - SERVICE LINE NUMBER

SV1*HC:A0422:RH*46*UN*1***1:2:3:4**Y~

SV1 - PROFESSIONAL SERVICE

DTP*472*D8*20050208~

DTP - SERVICE DATE

REF*6R*1003~

REF - LINE CONTROL NUMBER

LX*4~

LX - SERVICE LINE NUMBER

SV1*HC:A0382:RH*12.30*UN*1***1:2:3:4**Y~

SV1 - PROFESSIONAL SERVICE

DTP*472*D8*20050208~

DTP - SERVICE DATE

REF*6R*1004~

REF - LINE CONTROL NUMBER

TRAILER

SE*52*000017712~

SE TRANSACTION SET TRAILER