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*005010X223A2~
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*ANYWHERE*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
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*47*987654~
SE TRANSACTION SET TRAILER