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

Example 4: Orthodontic Treatment Plan

Orthodontic treatment plan, patient is not the subscriber; the payer is a commercial payer.

SUBSCRIBER: Jane Smith

PAYER ID #: SSN

SSN: 111-22-3333

PATIENT: Ted Smith

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

SEX: M

DOB: 10/29/1991

SUBMITTER: Dr. John Doe

ETIN#: 940001

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

SERVICES: Treatment plan for orthodontic care: 36 month at $4,000.

BANDING DATE: 4/15/2006

ELECTRONIC PATH: Billing provider submits claim directly to the payer.

Transmission Explanation

HEADER

ST*837*0322*005010X224~

ST TRANSACTION SET HEADER

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

BHT TRANSACTION SET HIERARCH AND CONTROL INFORMATION

1000A SUBMITTER

NM1*41*2*JOHN DOE*****46*940001~

PER*IC*SALLY*TE*7175555555~

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

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*1~

HIERARCHAL LEVEL 2

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

SBR SUBSCRIBER INFORMATION

2010BA SUBSCRIBER NAME

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

NM1 SUBSCRIBER 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 NM1 PATIENT NAME

NM1*QC*1*SMITH*TED~

N3*236 N MAIN ST~

N3 PATIENT ADDRESS

N4*MIAMI*FL*33413~

N4 PATIENT CITY

DMG*D8*19911029*M~

DMG PATIENT DEMOGRAPHIC INFORMATION

2300 CLAIM

CLM*SMITH788*4000***11:B:1*Y*A*Y*I~

CLM HEALTH CLAIM INFORMATION

DTP*452*D8*20061115~

DTP APPLIANCE PLACEMENT DATE

DN1*36~

DN1 ORTHODONTIC TOTAL MONTHS OF TREATMENT

2400 SERVICE LINE

LX*1~

LX SERVICE LINE NUMBER

SV3*AD:D8080*4000****1~

SV3 DENTAL SERVICE

TRAILER

SE*27*0322~

SE TRANSACTION SET TRAILER