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

Example 6: Chiropractic

Patient is the same person as the Subscriber. Payer is Medicare Part B. The claim is submitter directly to Medicare, the submitter being the provider.

SUBSCRIBER/PATIENT: Matthew J Williamson

ADDRESS: 128 Broadcreek, Baltimore, MD 21234

SEX: M

DOB: 1/10/1925

PAYER ID NUMBER: SSN

SSN: 123456789A

DESTINATION PAYER: Medicare Part B Maryland

PAYER ADDRESS: 1946 Greenspring Drive, Timonium, MD 21093

RECEIVER: Medicare Part B Maryland

EDI #: 12345

BILLING PROVIDER/SENDER: David M Greene, DC

ADDRESS: 1264 Oakwood Ave, Baltimore, MD 21236

EDI#: S01057

CONTACT PERSON AND PHONE NUMBER: Kathi Wilmoth 4105558888

PATIENT ACCOUNT NUMBER: 125WILL

CASE: Acute Back Pain

SERVICES: Chiropractic Manipulative Treatment - POS=Office

DATE OF SERVICE: 2/15/2005

CHARGE: $145.50

Initial Treatment Date: 01/15/20050

Acute Manifestation Date: 01/10/2005

Last X-Ray Date: 01/13/2005

TOTAL CHARGES: $145.50

ELECTRONIC ROUTE: Billing provider (sender) direct to Maryland Medicare Part B

Transmission Explanation

HEADER

ST*837*3701*005010X222~

ST TRANSACTION SET HEADER

BHT*0019*00*007227*20050215*075420*CH~

BHT BEGINNING OF HIERARCHICAL TRANSACTION

1000A SUBMITTER

NM1*41*2*DAVID GREEN*****46*S01057~

NM1 SUBMITTER

PER*IC*KATHY SMITH*TE*4105558888~

PER SUBMITTER EDI CONTACT INFORMATION

1000B RECEIVER

NM1*40*2*MEDICARE PART B MARYLAND*****46*12345~

NM1 RECEIVER NAME

2000A BILLING PROVIDER HL LOOP

HL*1**20*1~

HL - BILLING PROVIDER

2010AA BILLING PROVIDER

NM1*85*1*GREENE*DAVID*M***XX*1234567890~

NM1 BILLING PROVIDER NAME

N3*1264 OAKWOOD AVE~

N3 BILLING PROVIDER ADDRESS

N4*BALTIMORE*MD*21236~

N4 BILLING PROVIDER LOCATION

REF*EI*987654321~

REF BILLING PROVIDER SECONDARY ID

PER*IC*DR*TE*4105551212~

PER BILLING PROVIDER CONTACT INFORMATION

2000B SUBSCRIBER HL LOOP

HL*2*1*22*0~

HL - SUBSCRIBER

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

SBR SUBSCRIBER INFORMATION

2010BA SUBSCRIBER

NM1*IL*1*WILLIAMSON*MATTHEW*J***MI*123456789A~

NM1 SUBSCRIBER NAME

N3*128 BROADCREEK~

N3 SUBSCRIBER ADDRESS

N4*BALTIMORE*MD*21234~

N4 SUBSCRIBER CITY

DMG*D8*19250110*M~

DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

2010BB SUBSCRIBER / PAYER

NM1*PR*2*MEDICARE PART B MARYLAND*****PI*C12345~

NM1 PAYER NAME

2300 CLAIM

CLM*125WILL*145.5**11:B:1*Y*A*Y*Y~

CLM CLAIM LEVEL INFORMATION

DTP*454*D8*20050115~

DTP - INITIAL TREATMENT DATE

DTP*453*D8*20050110~

DTP - ACUTE MANIFESTATION DATE

DTP*455*D8*20050113~

DTP - LAST X-RAY DATE

CR2********A**CHRONIC PAIN AND DISCOMFORT~

CR2 SPINAL MANIPULATION SERVICE INFORMATION

HI*BK:7215~

HI HEALTH CARE DIAGNOSIS

2400 SERVICE LINE

LX*1~

LX SERVICE LINE COUNTER

SV1*HC:98940*145.5*UN*1**1~

SV1 - PROFESSIONAL SERVICE

DTP*472*D8*20050215~

DTP DATE - SERVICE DATE(S)

REF*6R*01~

REF - LINE ITEM CONTROL NUMBER

TRAILER

SE*29*3701~

SE TRANSACTION SET TRAILER