Example 2a: Claim From Billing Provider to Payer A

Transmission Explanation

HEADER

ST*837*0002*005010X224~

ST TRANSACTION SET CONTROL NUMBER

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

BHT TRANSACTION SET HIERARCHY AND CONTROL INFORMATION

1000A SUBMITTER

NM1*41*2*PREMIER BILLING SERVICE*****46*567890~

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

2010AA BILLING PROVIDER

NM1*85*2*DENTAL ASSOCIATES*****XX*4567890123~

NM1 BILLING PROVIDER NAME

N3*234 SEAWAY ST~

N3 BILLING PROVIDER ADDRESS

N4*MIAMI*FL*33111~

N4 BILLING PROVIDER CITY

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*JS00111223333~

NM1 SUBSCRIBER'S 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 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*200***11:B:1*Y*A*Y*I~

CLM HEALTH CLAIM INFORMATION

DTP*472*D8*20061109~

DTP DATE - SERVICE DATE

REF*D9*111222333444~

REF VAN CLAIM NUMBER

2310B RENDERING PROVIDER

NM1*82*1*KILDARE*BEN****XX*6789012345~

NM1 RENDERING PROVIDER’S NAME

PRV*PE*PXC*1223P0221X~

PRV RENDERING PROVIDER INFORMATION

2400 SERVICE LINE

LX*1~

LX SERVICE LINE NUMBER

SV3*AD:D3320*200****1~

SV3 DENTAL SERVICE

TOO*JP*5~

TOO TOOTH NUMBER SURFACE(S)

TRAILER

SE*29*0002~

SE TRANSACTION SET TRAILER

Payer A returned an electronic remittance advice (835) to the billing provider with the following amounts and claim adjustment reason codes:

SUBMITTED CHARGES (CLP003): 200.00

AMOUNT PAID (CLP04): 150.00

PATIENT RESPONSIBILITY (CLP05): 50.00

The CAS at the claim level was:

CAS*PR*1*50*1~ (INDICATES A $50.00 DEDUCTIBLE PAYMENT IS DUE FROM PATIENT)

See the introduction for a discussion on cross walking 835 to 837.