Section title: X12 EDI Examples
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ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X223

Example 1b: Two Claims for the Same Provider

For both claims the patient is the subscriber and the transaction is being directly submitted from the provider to the payer.

This example combines two claims for the same provider.

DESTINATION PAYER: TRICARE

PAYER ID: 99999

BILLING PROVIDER: Jones Hospital

BILLING PROVIDER ADDRESS: 225 MAIN STREET, ANYWHERE, PA, 17111

BILLING PROVIDER SPECIALTY: 282N00000X

BILLING PROVIDER EMPLOYER ID: 123456789

BILLING PROVIDER NPI: 1234567890

SUBMITTER ETIN: 12345

SUBMITTER CONTACT: Jane Doe

SUBMITTER CONTACT TELEPHONE: (111)222-3333

CLAIM #1:

SUBSCRIBER: John T. Doe

MEMBER ID: 030005074

SUBSCRIBER ADDRESS: 125 City Avenue, Anywhere, PA, 17111

DOB: November 11, 1968l

SEX: M

PATIENT ACCOUNT #: 756048Q

CLAIM AMOUNT: 89.95

TYPE OF BILL: 131

CLAIM DATE: March 15, 2005

PRINCIPAL DIAGNOSIS: 366.9

OTHER DIAGNOSIS: 401.9, 794.31

ATTENDING PHYSICIAN: John J. Jones

ATTENDING PHYSICIAN NPI: 1122334455

UPIN: U12345

PROCEDURES:

Rev code: 0305 HCPCS: 85025 Billed Amt: 13.39 Units: 1.

Rev code: 0730 HCPCS: 93010 Billed Amt: 76.56 Units: 3.

CLAIM #2:

SUBSCRIBER: Joe Smith

MEMBER ID: 123405074

SUBSCRIBER ADDRESS: 5 Main Street, Anywhere, PA, 17111

DOB: December 12, 1962

SEX: M

PATIENT ACCOUNT #: 756049Q

CLAIM AMOUNT: 50.00

TYPE OF BILL: 131

CLAIM DATE: April 1, 2005

PRINCIPAL DIAGNOSIS: 300.00

ATTENDING PHYSICIAN: Judy J. Jones

NPI: 9999999999

PROVIDER SPECIALTY: 363LP0200N

PROCEDURES:

Rev code: 0300 HCPCS: 85087 Billed Amt: 50.00 Units: 1.

Transmission Explanation

HEADER

ST*837*987654*005010X223~

ST TRANSACTION SET HEADER

BHT*0019*00*0123*20050630*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*1112223333~

PER SUBMITTER EDI CONTACT INFORMATION

1000B RECEIVER NAME

NM1*40*2*TRICARE*****46*99999~

NM1 RECEIVER NAME

2000A BILLING PROVIDER

HL*1**20*1~

HL BILLING PROVIDER HIERARCHICAL LEVEL

PRV*BI*PXC*282N00000X~

PRV BILLING PROVIDER SPECIALTY

2010AA BILLING PROVIDER NAME

NM1*85*2*JONES HOSPITAL*****XX*1234567890~

NM1 BILLING PROVIDER NAME INCLUDING NATIONAL PROVIDER ID

N3*225 MAIN STREET~

N3 BILLING PROVIDER ADDRESS

N4*ANYWHERE*PA*17111~

N4 BILLING PROVIDER LOCATION

REF*EI*123456789~

REF BILLING PROVIDER TAX IDENTIFICATION NUMBER

2000B SUBSCRIBER HL LOOP

HL*2*1*22*0~

HL SUBSCRIBER HIERARCHICAL LEVEL

SBR*P*18*******CH~

SBR SUBSCRIBER INFORMATION

2010BA SUBSCRIBER NAME LOOP

NM1*IL*1*DOE*JOHN*T***MI*030005074~

NM1 SUBSCRIBER NAME

N3*125 CITY AVENUE~

N3 SUBSCRIBER ADDRESS

N4*CENTERVILLE*PA*17111~

N4 SUBSCRIBER LOCATION

DMG*D8*19681111*M~

DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

2010BB PAYER NAME LOOP

NM1*PR*2*TRICARE*****PI*99999~

NM1 PAYER NAME

2300 CLAIM INFORMATION

CLM*756048Q*89.95**13:A:1*C*Y*Y~

CLM CLAIM LEVEL INFORMATION

DTP*434*RD8*20050315-20050315~

DTP STATEMENT DATES

CL1*1**01~

CL1 INSTITUTIONAL CLAIM CODE

HI*BK:3669~

HI PRINCIPAL DIAGNOSIS CODES

HI*BF:4019*BF:79431~

HI OTHER DIAGNOSIS INFORMATION

2310A ATTENDING PROVIDER NAME

NM1*71*1*JONES*JOHN*J***XX*1122334455~

NM1 ATTENDING PROVIDER

REF*1G*U12345~

REF ATTENDING PROVIDER SECONDARY IDENTIFICATION

2400 SERVICE LINE

LX*1~

LX SERVICE LINE COUNTER

SV2*0305*HC:85025*13.39*UN*1~

SV2 INSTITUTIONAL SERVICE

DTP*472*D8*20050315~

DTP DATE - SERVICE DATES

2400 SERVICE LINE

LX*2~

LX SERVICE LINE COUNTER

SV2*0730*HC:93010*76.56*UN*3~

SV2 INSTITUTIONAL SERVICE

DTP*472*D8*20050315~

DTP DATE - SERVICE DATES

2000B SUBSCRIBER HL LOOP

HL*3*1*22*0~

HL SUBSCRIBER HIERARCHICAL LEVEL

SBR*P*18*******CH~

SBR SUBSCRIBER INFORMATION

2010BA SUBSCRIBER NAME LOOP

NM1*IL*1*SMITH*JOE****MI*123405074~

NM1 SUBSCRIBER NAME

N3*5 MAIN STREET~

N3 SUBSCRIBER ADDRESS

N4*ANYWHERE*PA*17111~

N4 SUBSCRIBER LOCATION

DMG*D8*19621210*M~

DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

2010BB PAYER NAME LOOP

NM1*PR*2*TRICARE*****PI*99999~

NM1 PAYER NAME

2300 CLAIM INFORMATION

CLM*756049Q*50**13:A:1*C*Y*Y~

CLM CLAIM LEVEL INFORMATION

DTP*434*RD8*20050401-20050401~

DTP STATEMENT DATES

CL1*1**01~

CL1 INSTITUTIONAL CLAIM CODE

HI*BK:30000~

HI PRINCIPAL DIAGNOSIS CODES

2310A ATTENDING PROVIDER NAME

NM1*71*1*JONES*JUDY*J***XX*9999999999~

NM1 ATTENDING PROVIDER

PRV*AT*PXC*363LP0200N~

PRV - ATTENDING PROVIDER SPECIALTY INFORMATION

2400 SERVICE LINE

LX*1~

LX SERVICE LINE COUNTER

SV2*0300*HC:85087*50*UN*1~

SV2 INSTITUTIONAL SERVICE

DTP*472*D8*20050401~

DTP DATE - SERVICE DATES

TRAILER

SE*48*987654~

SE TRANSACTION SET TRAILER