Section title: X12 EDI Examples
back to previous

ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X223

Example 2a: Automobile Accident

CLAIM TYPE: AUTOMOBILE ACCIDENT

TYPE OF BILL: HOSPITAL

PRIMARY PAYER: PROPERTY & CASUALTY INSURER

THE PATIENT IS A DIFFERENT PERSON THAN THE SUBSCRIBER. THE PAYER IS A COMMERCIAL PROPERTY & CASUALTY INSURANCE COMPANY.

DATE OF ACCIDENT: 10/31/2005

SUBSCRIBER: HAL HOWLING

SUBSCRIBER ADDRESS: 327 BRONCO DRIVE, GETAWAY, CA, 99999

POLICY NUMBER: B999-777-91G

INSURANCE COMPANY: HEISMAN INSURANCE COMPANY

CLAIM NUMBER: 32-3232-32

PATIENT: RON MEXICO

PATIENT ADDRESS: 32 BUFFALO RUN, ROCKING HORSE, CA, 99666

SEX: M

DOB: 06/01/48

DESTINATION PAYER/RECEIVER: HEISMAN INSURANCE COMPANY

PAYER ADDRESS: 1 TROPHY LANE, NY, NY, 10032

PAYER ID: 999888777

BILLING PROVIDER/SENDER: HALL OF FAME MEMORIAL HOSPITAL

TIN: 737373737

NATIONAL PROVIDER IDENTIFIER: 2365259638

ADDRESS: 1 CANTON ROAD, BROKEN FIELD, CA, 99998

PAY-TO-PROVIDER: HALL OF FAME MEMORIAL HOSPITAL

ATTENDING PROVIDER: VINCENT LOMBARDO, MD

PATIENT ACCOUNT NUMBER: 000-00-0032

CASE: THE PATIENT WAS A PASSENGER IN THE SUBSCRIBER’S AUTOMOBILE, AND THE PATIENT REPORTS THAT HIS HAND WAS CUT WHEN THE CAR WAS STRUCK IN THE REAR.

DIAGNOSIS: 884.2, E975.0, E986.0

SERVICES RENDERED: OUTPATIENT E/R VISIT, LACERATION REPAIR, HISTOLOGY TEST

DOS = 10/31/2005, POS = E/R, TOS = OUTPATIENT

CHARGES: E/R ROOM = $150.00, LACERATION REPAIR = $75.00, DNA TEST = $100.00, E/R ATTENDING PHYSICIAN = $220.00. TOTAL CHARGES = $545.00.

Transmission Explanation

HEADER

ST*837*557766*005010X223~

ST TRANSACTION SET HEADER

BHT*0019*00*0324*20051111*1800*CH~

BHT BEGINNING OF HIERARCHICAL TRANSACTION

1000A SUBMITTER

NM1*41*2*HALL OF FAME MEMORIAL HOSPITAL*****46*737373737~

NM1 SUBMITTER NAME

PER*IC*KATE CASEY*TE*7152569877~

PER SUBMITTER EDI CONTACT INFORMATION

1000B RECEIVER

NM1*40*2*HEISMAN INSURANCE COMPANY*****46*999888777~

NM1 RECEIVER NAME

2000A BILLING PROVIDER HL LOOP

HL*1**20*1~

PRV*BI*PXC*203BA0200N~

PRV BILLING PROVIDER SPECIALTY

NM1*85*2*HALL OF FAME MEMORIAL HOSPITAL*****XX*2365259638~

NM1 BILLING PROVIDER NAME

N3*1 CANTON ROAD~

N3 BILLING PROVIDER ADDRESS

N4*BROKEN FIELD*CA*99998~

N4 BILLING PROVIDER LOCATION

REF*EI*737373737~

REF BILLING PROVIDER SECONDARY IDENTIFICATION

2000B SUBSCRIBER HL LOOP

HL*2*1*22*1~

SBR*P********AM~

SBR SUBSCRIBER INFORMATION

2010BA SUBSCRIBER

NM1*IL*1*HOWLING*HAL****MI*B999777791G~

NM1 SUBSCRIBER NAME

2010BB PAYER

NM1*PR*2*HEISMAN INSURANCE COMPANY*****PI*999888777~

NM1 PAYER NAME

2000C PATIENT HL LOOP

HL*3*2*23*0~

PAT*21~

PAT PATIENT INFORMATION

NM1*QC*1*MEXICO*RON~

NM1 PATIENT NAME

N3*32 BUFFALO RUN~

N3 PATIENT ADDRESS

N4*ROCKING HORSE*CA*99666~

N4 PATIENT CITY/STATE/ZIP CODE

DMG*D8*19480601*M~

DMG PATIENT DEMOGRAPHIC INFORMATION

REF*Y4*32323232~

REF PROPERTY AND CASUALTY CLAIM NUMBER

2300 CLAIM

CLM*67236695521*545**13:A:1*A*Y*Y~

DTP*434*RD8*20051031-20051101~

DTP STATEMENT DATES

CL1*3*7*1~

CL1 INSTITUTIONAL CLAIM CODE

REF*LU*CA~

REF AUTO ACCIDENT STATE

HI*BK:8842~

HI PRINCIPLE DIAGNOIS

HI*PR:8842~

HI PATIENT’S REASON FOR VISIT

HI*BN:E9750*BN:E9860~

HI EXTERNAL CAUSE OF INJURY

2310A ATTENDING PROVIDER NAME

NM1*71*1*LOMBARDO*VINCENT****XX*2533698543~

NM1 ATTENDING PROVIDER NAME

2400 SERVICE LINE NUMBER

LX*1~

LX SERVICE LINE NUMBER

SV2*0450*HC:98765*150*UN*1~

SV2 INSTITUTIONAL SERVICE LINE

DTP*472*D8*20051031~

DTP DATE - SERVICE DATE

LX*2~

LX SERVICE LINE NUMBER

SV2*0360*HC:26591*75*UN*1~

SV2 INSTITUTIONAL SERVICE LINE

DTP*472*D8*20051031~

DTP DATE - SERVICE DATE

LX*3~

LX SERVICE LINE NUMBER

SV2*0312*HC:86225*100*UN*2~

SV2 INSTITUTIONAL SERVICE LINE

DTP*472*D8*20051031~

DTP DATE - SERVICE DATE

LX*4~

LX SERVICE LINE NUMBER

SV2*0360*HC:99283*220*UN*1~

SV2 INSTITUTIONAL SERVICE LINE

DTP*472*D8*20051031~

DTP DATE - SERVICE DATE

TRAILER

SE*43*557766~

SE - TRANSACTION SET TRAILER