Section title: X12 EDI Examples
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ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X224

Example 06: Multiple Tooth Numbers

This dental claim scenario shows the reporting of multiple tooth numbers on a single service line. Anytime multiple tooth numbers are reported on a single service line, the SV306 should not present. The service being performed is a partial denture (D5214) that replaces the missing teeth: 18, 19, 21, 30 and 31.

Transmission Explanation

HEADER

ST*837*0001*005010X224A2~

ST TRANSACTION SET HEADER

BHT*0019*00*1000002*20140305*0745*CH~

BHT TRANSACTION SET HIERARCH AND CONTROL INFORMATION

1000A SUBMITTER

NM1*41*2*XYZ CLEARINGHOUSE*****46*321123~

PER*IC*XYZ CLEARINGHOUSE, INC.*TE*8005551212*EX*123*EM*PRODUCTIONSUPPORT@XYZCLEARINGHOUSE.COM~

PER SUBMITTER EDI CONTACT INFORMATION

1000B RECEIVER

NM1*40*2*ACME DENTAL PAYER*****46*12345~

NM1 RECEIVER

2000A BILLING PROVIDER HL LOOP

HL*1**20*1~

HIERARCHAL LEVEL 1

2010AA BILLING PROVIDER

NM1*85*2*ANYTOWN DENTAL*****XX*1234567984~

NM1 BILLING PROVIDER

N3*926 MAIN ST~

N3 BILLING PROVIDER ADDRESS

N4*ANYTOWN*FL*327147244~

N4 BILLING PROVIDER CITY

REF*EI*222222222~

REF BILLING PROVIDER TAX IDENTIFIER

PER*IC*ANYTOWN DENTAL*TE*4075551213~

PER BILLING PROVIDER CONTACT INFORMATION

2000B SUBSCRIBER HL LOOP

HL*2*1*22*0~

HIERARCHAL LEVEL 2

SBR*P*18*12345687******CI~

SBR SUBSCRIBER INFORMATION

2010BA SUBSCRIBER NAME

NM1*IL*1*SUBLAST*SUBFIRST*M***MI*123456~

NM1 SUBSCRIBER NAME

N3*654 ANYWHERE DR~

N3 SUBSCRIBER ADDRESS

N4*ANYTOWN*FL*32000~

N4 SUBSCRIBER CITY

DMG*D8*19710101*M~

DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

2010BB SUBSCRIBER/PAYER

NM1*PR*2*ACME DENTAL PAYER*****PI*11111~

NM1 PAYER NAME

2300 CLAIM

CLM*1191*900***11:B:1*Y*C*Y*Y~

CLM HEALTH CLAIM INFORMATION

PWK*OZ*EL***AC*NEA123456798~

PWK CLAIM SUPPLEMENTAL INFORMATION

REF*D9*0001958960000001~

REF SECONDARY IDENTIFICATION

2310A RENDERING PROVIDER

NM1*82*1*RENDERLAST*RENDERFIRST****XX*1234567893~

NM1 RENDERING PROVIDER NAME

PRV*PE*PXC*1223G0001X~

PRV RENDERING PROVIDER SPECIALTY INFORMATION

2400 SERVICE LINE

LX*1~

LX SERVICE LINE NUMBER

SV3*AD:D5214*900~

SV3 DENTAL SERVICE

TOO*JP*31~

TOO TOOTH NUMBER/SURFACES

TOO*JP*30~

TOO TOOTH NUMBER/SURFACES

TOO*JP*21~

TOO TOOTH NUMBER/SURFACES

TOO*JP*19~

TOO TOOTH NUMBER/SURFACES

TOO*JP*18~

TOO TOOTH NUMBER/SURFACES

TRAILER

SE*31*0001~

SE TRANSACTION SET TRAILER