ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X223
Example 1a: Institutional Claim
The examples in this section have been created with a mixture of uppercase and lowercase letters. This demonstrates that this is an acceptable representation.
PRIMARY PAYER SUBSCRIBER: John T Doe
SUBSCRIBER ADDRESS: 125 City Avenue, Centerville, PA 17111
SEX: M
DOB: 11/11/1926
MEDICARE INSURANCE ID#: 030005074A
PAYER ID #: 00435
PATIENT: Same as Primary Subscriber
DESTINATION PAYER: Medicare B
SUBMITTER: Jones Hospital
EDI#: 12345
RECEIVER: Medicare
EDI#: 00120
BILLING PROVIDER: Jones Hospital
NPI: 9876540809
TIN: 567891234
MEDICARE PROVIDER: #330127
ADDRESS: 225 Main Street Barkley Building, Centerville, PA 17111
ATTENDING PHYSICIAN: John J Jones
UPIN #: B99937
PATIENT ACCOUNT NUMBER: 756048Q
DATE OF ADMISSION: 09/11/96
STATEMENT PERIOD DATE: 09/11/96 - 09/11/96
PLACE OF SERVICE: Inpatient Hospital
Occurrence Codes and Dates:
A1 11/11/26
A2 11/01/91
B1 11/11/26
B2 01/01/87
Condition Codes: 09
Value Codes: A2 $15.31
PRINCIPAL DIAGNOSIS CODE: 366.9
SECONDARY DIAGNOSIS CODES:
401.9
794.31
NUMBER OF COVERED DAYS: 1
SERVICES:
INSTITUTIONAL SERVICES RENDERED:
REVENUE CODE: 0305 HCPCS Procedure Code: 85025 Unit: 1 Price $13.39
REVENUE CODE: 0730 HCPCS Procedure Code: 93005 Unit: 1 Price: $76.54
TOTAL CHARGES: $89.93
SECONDARY PAYER SUBSCRIBER: Jane S Doe (wife)
SUBSCRIBER ADDRESS: 125 City Avenue, Centerville, PA 17111
SEX: F
DOB: 12/11/1927
STATE TEACHERS ID#: 222004433
PAYER ID #: 1135
Transmission Explanation
HEADER
ST*837*987654*005010X223A2~
ST TRANSACTION SET HEADER
BHT*0019*00*0123*19960918*0932*CH~
BHT BEGINNING OF HIERARCHICAL TRANSACTION
1000A SUBMITTER NAME
NM1*41*2*JONES HOSPITAL*****46*12345~
NM1 SUBMITTER NAME
PER*IC*JANE DOE*TE*9005555555~
PER SUBMITTER EDI CONTACT INFORMATION
1000B RECEIVER NAME
NM1*40*2*MEDICARE*****46*00120~
NM1 RECEIVER NAME
2000A BILLING PROVIDER
HL*1**20*1~
HL BILLING PROVIDER HIERARCHICAL LEVEL
PRV*BI*PXC*203BA0200N~
PRV BILLING PROVIDER SPECIALTY
2010AA BILLING PROVIDER NAME
NM1*85*2*JONES HOSPITAL*****XX*9876540809~
NM1 BILLING PROVIDER NAME INCLUDING NATIONAL PROVIDER ID
N3*225 MAIN STREET BARKLEY BUILDING~
N3 BILLING PROVIDER ADDRESS
N4*CENTERVILLE*PA*17111~
N4 BILLING PROVIDER LOCATION
REF*EI*567891234~
REF BILLING PROVIDER TAX IDENTIFICATION NUMBER
2000B SUBSCRIBER HL LOOP
HL*2*1*22*0~
HL SUBSCRIBER HIERARCHICAL LEVEL
SBR*P*18*******MB~
SBR SUBSCRIBER INFORMATION
2010BA SUBSCRIBER NAME LOOP
NM1*IL*1*DOE*JOHN*T***MI*030005074A~
NM1 SUBSCRIBER NAME
N3*125 CITY AVENUE~
N3 SUBSCRIBER ADDRESS
N4*CENTERVILLE*PA*17111~
N4 SUBSCRIBER LOCATION
DMG*D8*19261111*M~
DMG SUBSCRIBER DEMOGRAPHIC INFORMATION
2010BB PAYER NAME LOOP
NM1*PR*2*MEDICARE B*****PI*00435~
NM1 PAYER NAME
REF*G2*330127~
REF BILLING PROVIDER SECONDARY IDENTIFICATION
2300 CLAIM INFORMATION
CLM*756048Q*89.93***14:A:1**A*Y*Y~
CLM CLAIM LEVEL INFORMATION
DTP*434*RD8*19960911-19960911~
DTP STATEMENT DATES
CL1*3**01~
CL1 INSTITUTIONAL CLAIM CODE
HI*BK:3669~
HI PRINCIPAL DIAGNOSIS CODES
HI*BF:4019*BF:79431~
HI OTHER DIAGNOSIS INFORMATION
HI*BH:A1:D8:19261111*BH:A2:D8:19911101*BH:B1:D8:19261111*BH:B2:D8:19870101~
HI OCCURRENCE INFORMATION
HI*BE:A2:::15.31~
HI VALUE INFORMATION
HI*BG:09~
HI CONDITION INFORMATION
2310A ATTENDING PROVIDER NAME
NM1*71*1*JONES*JOHN*J~
NM1 ATTENDING PROVIDER
REF*1G*B99937~
REF ATTENDING PROVIDER SECONDARY IDENTIFICATION
2320 OTHER SUBSCRIBER INFORMATION
SBR*S*01*351630*STATE TEACHERS*****CI~
SBR OTHER SUBSCRIBER INFORMATION
OI***Y***Y~
OI OTHER INSURANCE COVERAGE INFORMATION
2330A OTHER SUBSCRIBER NAME
NM1*IL*1*DOE*JANE*S***MI*222004433~
NM1 OTHER SUBSCRIBER NAME
N3*125 CITY AVENUE~
N3 OTHER SUBSCRIBER ADDRESS
N4*CENTERVILLE*PA*17111~
N4 OTHER SUBSCRIBER CITY, STATE, ZIP CODE
2330B OTHER PAYER NAME
NM1*PR*2*STATE TEACHERS*****PI*1135~
NM1 OTHER PAYER NAME
2400 SERVICE LINE
LX*1~
LX SERVICE LINE COUNTER
SV2*0305*HC:85025*13.39*UN*1~
SV2 INSTITUTIONAL SERVICE
DTP*472*D8*19960911~
DTP DATE - SERVICE DATES
2400 SERVICE LINE
LX*2~
LX SERVICE LINE COUNTER
SV2*0730*HC:93005*76.54*UN*3~
SV2 INSTITUTIONAL SERVICE
DTP*472*D8*19960911~
DTP DATE - SERVICE DATES
TRAILER
SE*42*987654~
SE TRANSACTION SET TRAILER