ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X224
Example 04: Orthodontic Treatment Plan
Orthodontic treatment plan, patient is not the subscriber; the payer is a commercial payer.
SUBSCRIBER: Jane Smith
PAYER ID #: SSN
SSN: 111-22-3333
PATIENT: Ted Smith
PATIENT ADDRESS: 236 N. Main St., Miami, FL. 33413
SEX: M
DOB: 10/29/1991
SUBMITTER: Dr. John Doe
ETIN#: 940001
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
SERVICES: Treatment plan for orthodontic care: 36 month at $4,000.
BANDING DATE: 4/15/2006
ELECTRONIC PATH: Billing provider submits claim directly to the payer.
Transmission Explanation
HEADER
ST*837*0322*005010X224~
ST TRANSACTION SET HEADER
BHT*0019*00*0123*20061123*1023*CH~
BHT TRANSACTION SET HIERARCH AND CONTROL INFORMATION
1000A SUBMITTER
NM1*41*2*JOHN DOE*****46*940001~
PER*IC*SALLY*TE*7175555555~
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
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*1~
HIERARCHAL LEVEL 2
SBR*P********CI~
SBR SUBSCRIBER INFORMATION
2010BA SUBSCRIBER NAME
NM1*IL*1*SMITH*JANE****MI*111223333~
NM1 SUBSCRIBER NAME
2010BB SUBSCRIBER/PAYER
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~
NM1 PAYER NAME
2000C PATIENT HL LOOP
HL*3*2*23*0~
HIERARCHAL LEVEL 3
PAT*19~
PAT PATIENT INFORMATION
2010CA NM1 PATIENT NAME
NM1*QC*1*SMITH*TED~
N3*236 N MAIN ST~
N3 PATIENT ADDRESS
N4*MIAMI*FL*33413~
N4 PATIENT CITY
DMG*D8*19911029*M~
DMG PATIENT DEMOGRAPHIC INFORMATION
2300 CLAIM
CLM*SMITH788*4000***11:B:1*Y*A*Y*I~
CLM HEALTH CLAIM INFORMATION
DTP*452*D8*20061115~
DTP APPLIANCE PLACEMENT DATE
DN1*36~
DN1 ORTHODONTIC TOTAL MONTHS OF TREATMENT
2400 SERVICE LINE
LX*1~
LX SERVICE LINE NUMBER
SV3*AD:D8080*4000****1~
SV3 DENTAL SERVICE
TRAILER
SE*27*0322~
SE TRANSACTION SET TRAILER