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

Example 1: Commercial Health Insurance

The patient is a different person than the subscriber. The payer is a commercial health insurance company.

SUBSCRIBER: Jane Smith

KEY INSURANCE COMPANY ID #: SSN

SSN: 111-22-3333

PATIENT: Ted Smith

PATIENT ADDRESS: 236 N. Main St., Miami, Fl, 33413

SEX: M

DOB: 05/01/1992

PATIENT RELATIONSHIP: Child

DESTINATION PAYER: Insurance Company XYZ

RECEIVER: Insurance Company XYZ

ETIN#: 66783JJT

SUBMITTER: Premier Billing Service

ETIN#: TGJ23

BILLING PROVIDER: Dental Associates

NPI: 1234567890

TIN: 587654321

ADDRESS: 234 Seaway St., Miami, FL, 33111

RENDERING PROVIDER: Dr. Ben Kildare

NPI: 9876543210

PATIENT ACCOUNT NUMBER: 2-640-3774

DOS: 20061029

POS=Office

SERVICES RENDERED: Two surface amalgam on tooth #12 (mesial and occlusal surfaces) and prophy.

CHARGES: amalgam = $100.00, prophy = $50.00.

ELECTRONIC ROUTE: VAN submits claim on behalf of billing provider (submitter) to Insurance Company XYZ (receiver).

VAN CLAIM IDENTIFICATION NUMBER: 17312345600006351.

Transmission Explanation

HEADER

ST*837*3456*005010X224~

ST TRANSACTION SET HEADER

BHT*0019*00*0123*20061123*1023*CH~

BHT TRANSACTION SET HIERARCHY AND CONTROL INFORMATION

1000A SUBMITTER

NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~

NM1 SUBMITTER

PER*IC*JERRY*TE*7176149999~

PER SUBMITTER EDI CONTACT INFORMATION

1000B RECEIVER

NM1*40*2*INSURANCE COMPANY XYZ*****46*66783JJT~

NM1 RECEIVER

2000A BILLING PROVIDER HL LOOP

HL*1**20*1~

HIERARCHAL LEVEL 1

2010AA BILLING PROVIDER

NM1*85*2*DENTAL ASSOCIATES*****XX*1234567890~

NM1 BILLING PROVIDER NAME

N3*234 SEAWAY ST~

N3 BILLING PROVIDER ADDRESS

N4*MIAMI*FL*33111~

N4 BILLING PROVIDER LOCATION

REF*EI*587654321~

REF BILLING PROVIDER'S TAX IDENTIFICATION

2000B SUBSCRIBER HL LOOP

HL*2*1*22*1~

HIERARCHAL LEVEL 2

SBR*P********CI~

SBR SUBSCRIBER INFORMATION

2010BA SUBSCRIBER

NM1*IL*1*SMITH*JANE****MI*111223333~

NM1 SUBSCRIBER'S NAME

2010BB SUBSCRIBER/PAYER

NM1*PR*2*INSURANCE COMPANY XYZ*****PI*66783JJT~

NM1 PAYER'S NAME

2000C PATIENT'S HL LOOP

HL*3*2*23*0~

HIERARCHAL LEVEL 3

PAT*19~

PAT PATIENT INFORMATION

2010CA PATIENT

NM1*QC*1*SMITH*TED~

NM1 PATIENT'S NAME

N3*236 N MAIN ST~

N3 PATIENT'S ADDRESS

N4*MIAMI*FL*33413~

N4 PATIENT'S CITY

DMG*D8*19920501*M~

DMG PATIENT DEMOGRAPHIC INFORMATION

2300 CLAIM

CLM*26403774*150***11:B:1*Y*A*Y*I~

CLM HEALTH CLAIM INFORMATION

DTP*472*D8*20061029~

DTP DATE - SERVICE DATE

REF*D9*17312345600006351~

REF VAN CLAIM NUMBER

2310B RENDERING PROVIDER

NM1*82*1*KILDARE*BEN****XX*9876543210~

NM1 RENDERING PROVIDER’S NAME

PRV*PE*PXC*1223G0001X~

PRV RENDERING PROVIDER INFORMATION

2400 SERVICE LINE

LX*1~

LX SERVICE LINE NUMBER

SV3*AD:D2150*100****1~

SV3 DENTAL SERVICE

TOO*JP*12*M:O~

TOO TOOTH NUMBER/SURFACES

2400 SERVICE LINE

LX*2~

LX SERVICE LINE NUMBER

SV3*AD:D1110*50****1~

SV3 DENTAL SERVICE

TRAILER

SE*31*3456~

SE TRANSACTION SET TRAILER