ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X224
Example 03: Predetermination of Benefits
Predetermination of benefits, the patient is the subscriber, the payer is a commercial payer.
SUBSCRIBER: Jane Smith
ADDRESS: 236 N. Main St., Miami, Fl, 33413
SEX: F
DOB: 05/01/43
PAYER ID #: SSN
SSN: 111-22-3333
PATIENT: Jane Smith
SUBMITTER: ABC Clearinghouse
ETIN#: ABC123
DESTINATION PAYER (Receiver): Key Insurance Company
PAYER TIN: 999996666
BILLING PROVIDER: Dr. John Doe
ADDRESS: 123 Tooth Drive, Miami, FL. 33411
NPI: 2345678901
TIN#: 587654321
RENDERING PROVIDER: Dr. John Doe
PATIENT ACCOUNT NUMBER: SMITH878
POS=Office
SERVICE PREDETERMINED: Single crown on tooth #13 at $750.00.
This is the initial placement of the crown.
Radiograph is being sent to the payer in the mail.
ELECTRONIC PATH: VAN submits the claim on behalf of the billing provider to the payer who adjudicates the claim. VAN Claim # 123123123.
Transmission Explanation
HEADER
ST*837*0321*005010X224~
ST TRANSACTION SET HEADER
BHT*0019*00*0123*20061123*1023*CH~
BHT TRANSACTION SET HIERARCH AND CONTROL INFORMATION
1000A SUBMITTER
NM1*41*2*ABC CLEARINGHOUSE*****46*ABC123~
NM1 SUBMITTER
PER*IC*JERRY*TE*7176149999~
PER SUBMITTER EDI CONTACT INFORMATION
1000B RECEIVER
NM1*40*2*KEY INSURANCE COMPANY*****46*999996666~
NM1 RECEIVER
2000A BILLING PROVIDER HL LOOP
HL*1**20*1~
HIERARCHAL LEVEL 1
PRV*BI*PXC*1223G0001X~
PRV BILLING PROVIDER INFORMATION
2010AA BILLING PROVIDER
NM1*85*1*JOHN*DOE****XX*2345678901~
NM1 BILLING PROVIDER NAME
N3*123 TOOTH DRIVE~
N3 BILLING PROVIDER ADDRESS
N4*MIAMI*FL*33411~
N4 BILLING PROVIDER CITY
REF*EI*587654321~
REF BILLING PROVIDER TAX IDENTIFIER
2000B SUBSCRIBER HL LOOP
HL*2*1*22*0~
HIERARCHAL LEVEL 2
SBR*P*18*******CI~
SBR SUBSCRIBER INFORMATION
2010BA SUBSCRIBER NAME
NM1*IL*1*SMITH*JANE****MI*111223333~
NM1 SUBSCRIBER NAME
N3*236 N MAIN ST~
N3 SUBSCRIBER ADDRESS
N4*MIAMI*FL*33413~
N4 SUBSCRIBER CITY
DMG*D8*19430501*F~
DMG SUBSCRIBER DEMOGRAPHIC INFORMATION
2010BB SUBSCRIBER/PAYER
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~
NM1 PAYER NAME
2300 CLAIM
CLM*SMITH878*750***11:B:1*Y*A*Y*I**********PB~
CLM HEALTH CLAIM INFORMATION
PWK*RB*BM***AC*SMITHJANE11122333~
PWK CLAIM SUPPLEMENTAL INFORMATION
REF*D9*123123123~
REF VAN CLAIM NUMBER
2400 SERVICE LINE
LX*1~
LX SERVICE LINE NUMBER
SV3*AD:D2750*750***I*1~
SV3 DENTAL SERVICE
TOO*JP*13~
TOO TOOTH NUMBER/SURFACE(S)
TRAILER
SE*25*0321~
SE TRANSACTION SET TRAILER