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

Example 2: Coordination of Benefits (COB)

Coordination of benefits; the patient is not the subscriber; payers are commercial health insurance companies.

SUBSCRIBER FOR PAYER A: Jane Smith

DOB: 05/01/43

PAYER A ID NUMBER: JS00111223333

SUBSCRIBER FOR PAYER B: Jack Smith

DOB: 10/22/43

PAYER B ID NUMBER: T55TY666

PATIENT: Ted Smith

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

SEX: M

DOB: 05/01/1992

PATIENT RELATIONSHIP: Child

SUBMITTER: Premier Billing Service

ETIN#: 567890

DESTINATION PAYER A (Receiver): Key Insurance Company

PAYER A ADDRESS: 3333 Ocean St., South Miami, FL, 33000

PAYER A ID NUMBER: (TIN) 999996666

DESTINATION PAYER B (Receiver): Great Prairies Health

PAYER B ADDRESS: 4456 South Shore Blvd., Chicago, IL 44444

ETIN#: 123456789

BILLING PROVIDER: Dental Associates

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

NPI: 4567890123

TIN: 587654321

RENDERING PROVIDER: Dr. Ben Kildare

NPI: 6789012345

PATIENT ACCOUNT NUMBER: 2-640-3774

DOS=11/09/2006

POS=Office

SERVICES RENDERED: Root Canal treatment for tooth #5 at $200.00.

ELECTRONIC ROUTE: VAN submits claim on behalf of billing provider to Payer A (receiver) (Example 2A) who adjudicates the claim. Payer A transmits back an 835 to the billing provider. The VAN then submits a second claim on behalf of the billing provider to Payer B (receiver) (Example 2B).

VAN CLAIM IDENTIFICATION NUMBER FOR PAYER A: 111222333444.

VAN CLAIM IDENTIFICATION NUMBER FOR PAYER B: 444333222111.