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

Example 5: Sales Tax

This dental claim scenario shows the reporting of one sales tax amount for all the services on the claim. The CDT2014 Sales Tax Code, D9985, is new to the industry and should be used when reporting sales tax on a dental claim. The Sales Tax AMT segment should no longer be used.

Transmission Explanation

HEADER

ST*837*0001*005010X224~

ST TRANSACTION SET HEADER

BHT*0019*00*1000002*20140305*0745*CH~

BHT TRANSACTION SET HIERARCH AND CONTROL INFORMATION

1000A SUBMITTER

NM1*41*2*XYZ CLEARINGHOUSE*****46*321123~

PER*IC*XYZ CLEARINGHOUSE, INC.*TE*8005551212*EX*123*EM*PRODUCTIONSUPPORT@XYZCLEARINGHOUSE.COM~

PER SUBMITTER EDI CONTACT INFORMATION

1000B RECEIVER

NM1*40*2*ACME DENTAL PAYER*****46*12345~

NM1 RECEIVER

2000A BILLING PROVIDER HL LOOP

HL*1**20*1~

HIERARCHAL LEVEL 1

2010AA BILLING PROVIDER

NM1*85*2*ANYTOWN DENTAL*****XX*1234567984~

NM1 BILLING PROVIDER

N3*926 MAIN ST~

N3 BILLING PROVIDER ADDRESS

N4*ANYTOWN*FL*327147244~

N4 BILLING PROVIDER CITY

REF*EI*222222222~

REF BILLING PROVIDER TAX IDENTIFIER

PER*IC*ANYTOWN DENTAL*TE*4075551213~

PER BILLING PROVIDER CONTACT INFORMATION

2000B SUBSCRIBER HL LOOP

HL*2*1*22*0~

HIERARCHAL LEVEL 2

SBR*P*18*12345687******CI~

SBR SUBSCRIBER INFORMATION

2010BA SUBSCRIBER NAME

NM1*IL*1*SUBLAST*SUBFIRST*M***MI*123456~

NM1 SUBSCRIBER NAME

N3*654 ANYWHERE DR~

N3 SUBSCRIBER ADDRESS

N4*ANYTOWN*FL*32000~

N4 SUBSCRIBER CITY

DMG*D8*19710101*M~

DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

2010BB SUBSCRIBER/PAYER

NM1*PR*2*BLUE EXAMPLE*****PI*11111~

NM1 PAYER NAME

2300 CLAIM

CLM*119033233*293.19***11:B:1*Y*C*Y*Y~

CLM HEALTH CLAIM INFORMATION

PWK*OZ*EL***AC*NEA123456798~

PWK CLAIM SUPPLEMENTAL INFORMATION

REF*D9*0001958960000001~

REF SECONDARY IDENTIFICATION

2310A RENDERING PROVIDER

NM1*82*1*RENDERLAST*RENDERFIRST****XX*1234567893~

NM1 RENDERING PROVIDER NAME

PRV*PE*PXC*1223G0001X~

PRV RENDERING PROVIDER SPECIALTY INFORMATION

2400 SERVICE LINE

LX*1~

LX SERVICE LINE NUMBER

SV3*AD:D7140*150~

SV3 DENTAL SERVICE

TOO*JP*31~

TOO TOOTH NUMBER/SURFACES

REF*6R*01~

REF SECONDARY IDENTIFICATION

LX*2~

LX SERVICE LINE NUMBER

SV3*AD:D0140*130~

SV3 DENTAL SERVICE

REF*6R*02~

REF SECONDARY IDENTIFICATION

LX*3~

LX SERVICE LINE NUMBER

SV3*AD:D9985*13.19~

SV3 DENTAL SERVICE

REF*6R*03~

REF SECONDARY IDENTIFICATION

TRAILER

SE*34*0001~

SE TRANSACTION SET TRAILER