Section title: X12 EDI Examples
back to previous

ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X224

Example 3: Predetermination of Benefits

Predetermination of benefits, the patient is the subscriber, the payer is a commercial payer.

SUBSCRIBER: Jane Smith

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

SEX: F

DOB: 05/01/43

PAYER ID #: SSN

SSN: 111-22-3333

PATIENT: Jane Smith

SUBMITTER: ABC Clearinghouse

ETIN#: ABC123

DESTINATION PAYER (Receiver): Key Insurance Company

PAYER TIN: 999996666

BILLING PROVIDER: Dr. John Doe

ADDRESS: 123 Tooth Drive, Miami, FL. 33411

NPI: 2345678901

TIN#: 587654321

RENDERING PROVIDER: Dr. John Doe

PATIENT ACCOUNT NUMBER: SMITH878

POS=Office

SERVICE PREDETERMINED: Single crown on tooth #13 at $750.00.

This is the initial placement of the crown.

Radiograph is being sent to the payer in the mail.

ELECTRONIC PATH: VAN submits the claim on behalf of the billing provider to the payer who adjudicates the claim. VAN Claim # 123123123.

Transmission Explanation

HEADER

ST*837*0321*005010X224~

ST TRANSACTION SET HEADER

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

BHT TRANSACTION SET HIERARCH AND CONTROL INFORMATION

1000A SUBMITTER

NM1*41*2*ABC CLEARINGHOUSE*****46*ABC123~

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

PRV*BI*PXC*1223G0001X~

PRV BILLING PROVIDER INFORMATION

2010AA BILLING PROVIDER

NM1*85*1*JOHN*DOE****XX*2345678901~

NM1 BILLING PROVIDER NAME

N3*123 TOOTH DRIVE~

N3 BILLING PROVIDER ADDRESS

N4*MIAMI*FL*33411~

N4 BILLING PROVIDER CITY

REF*EI*587654321~

REF BILLING PROVIDER TAX IDENTIFIER

2000B SUBSCRIBER HL LOOP

HL*2*1*22*0~

HIERARCHAL LEVEL 2

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

SBR SUBSCRIBER INFORMATION

2010BA SUBSCRIBER NAME

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

NM1 SUBSCRIBER NAME

N3*236 N MAIN ST~

N3 SUBSCRIBER ADDRESS

N4*MIAMI*FL*33413~

N4 SUBSCRIBER CITY

DMG*D8*19430501*F~

DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

2010BB SUBSCRIBER/PAYER

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

NM1 PAYER NAME

2300 CLAIM

CLM*SMITH878*750***11:B:1*Y*A*Y*I**********PB~

CLM HEALTH CLAIM INFORMATION

PWK*RB*BM***AC*SMITHJANE11122333~

PWK CLAIM SUPPLEMENTAL INFORMATION

REF*D9*123123123~

REF VAN CLAIM NUMBER

2400 SERVICE LINE

LX*1~

LX SERVICE LINE NUMBER

SV3*AD:D2750*750***I*1~

SV3 DENTAL SERVICE

TOO*JP*13~

TOO TOOTH NUMBER/SURFACE(S)

TRAILER

SE*25*0321~

SE TRANSACTION SET TRAILER