Example 2b: Claim from Billing Provider to Payer B

Transmission Explanation

HEADER

ST*837*0123*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*GREAT PRAIRIES HEALTH*****46*123456789~

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 TAX IDENTIFICATION

2000B SUBSCRIBER HL LOOP

HL*2*1*22*1~

HIERARCHAL LEVEL 2

SBR*S********CI~

SBR SUBSCRIBER INFORMATION

2010BA SUBSCRIBER

NM1*IL*1*SMITH*JACK****MI*T55TY666~

NM1 SUBSCRIBER'S NAME

2010BB SUBSCRIBER/PAYER

NM1*PR*2*GREAT PRAIRIES HEALTH*****PI*123456789~

NM1 PAYER 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*200***11:B:1*Y*A*Y*I~

CLM HEALTH CLAIM INFORMATION

DTP*472*D8*20061109~

DTP DATE - SERVICE DATE

REF*D9*444333222111~

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

2320 OTHER SUBSCRIBER INFORMATION

SBR*P*19*******CI~

SBR SUBSCRIBER INFORMATION - OTHER PAYERS

CAS*PR*1*50*1~

CAS CLAIM LEVEL ADJUSTMENTS AND AMOUNTS

AMT*D*150~

AMT COB - PAYER AMOUNT PAID ON CLAIM

OI***Y***I~

OI OTHER INSURANCE COVERAGE INFORMATION

2330A OTHER INSURED NAME

NM1*IL*1*SMITH*JANE****MI*JS00111223333~

NM1 OTHER NAME

N3*236 N MAIN ST~

N3 OTHER SUBSCRIBER'S ADDRESS

N4*MIAMI*FL*33413~

N4 OTHER SUBSCRIBER'S CITY

2330B OTHER PAYER NAME

NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~

NM1 OTHER PAYER NAME

DTP*573*D8*20061122~

DTP CLAIM PAID DATE

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*38*0123~

SE TRANSACTION SET TRAILER