ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X291
Example 01: Commercial Health Insurance
Patient is a different person than the Subscriber and does not have a unique payer-assigned identifier. Payer is commercial health insurance company.
SUBSCRIBER: Jane Smith
PATIENT ADDRESS: 236 N. Main St., Miami, Fl, 33413
TELEPHONE NUMBER: 305-555-1111
SEX: F
DOB: 05/01/43
EMPLOYER: ACME Inc.
GROUP #: 2222-SJ
KEY INSURANCE COMPANY ID #: JS00111223333
PATIENT: Ted Smith
PATIENT ADDRESS: 236 N. Main St., Miami, Fl, 33413
TELEPHONE NUMBER: 305-555-1111
SEX: M
DOB: 05/01/73
DESTINATION PAYER: Key Insurance Company
PAYER ADDRESS: 3333 Ocean St. South Miami, FL 33000
PAYER ID: 999996666
SUBMITTER: Premier Billing Service
EDI#: TGJ23
CONTACT PERSON AND PHONE NUMBER: JERRY, 305-555-2222 ext. 231
RECEIVER: Key Insurance Company
EDI #: 66783JJT
BILLING PROVIDER: Dr. Ben Kildare,
ADDRESS: 234 Seaway St, Miami, FL, 33111
NPI: 9876543210
TIN: 587654321
KEY INSURANCE COMPANY PROVIDER ID #: KA6663
Taxonomy Code: 203BF0100Y
PAY-TO PROVIDER: Kildare Associates
PROVIDER ADDRESS: 2345 Ocean Blvd, Miami, Fl 33111
RENDERING PROVIDER: Dr. Ben Kildare
PATIENT ACCOUNT NUMBER: 2-646-3774
CASE: Patient has sore throat.
INITIAL VISIT: DOS=10/03/06. POS=Office
SERVICES: Office visit, intermediate service, established patient, throat culture.
CHARGES: Office first visit = $40.00, Lab test for strep = $15.00
FOLLOW-UP VISIT: Predetermination request. Today's date assumed.
Antibiotics didn’t work (pain continues).
SERVICES: Office visit, intermediate service, established patient, mono screening.
CHARGES: Follow-up visit = $35.00, lab test for mono = $10.00.
TOTAL CHARGES FOR PREDETERMINATION REQUEST: $45.00.
ELECTRONIC ROUTE: Billing provider (sender), to VAN to Key Insurance Company (receiver). VAN claim identification number = 17312345600006351.
Transmission Explanation
HEADER
ST*837*0021*005010X291~
ST TRANSACTION SET HEADER
BHT*0019*00*244579*20061015*1023*CH~
BHT BEGINNING OF HIERARCHICAL TRANSACTION
1000A SUBMITTER
NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~
NM1 SUBMITTER NAME
PER*IC*JERRY*TE*3055552222*EX*231~
PER SUBMITTER EDI CONTACT INFORMATION
1000B RECEIVER
NM1*40*2*KEY INSURANCE COMPANY*****46*66783JJT~
NM1 RECEIVER NAME
2000A BILLING PROVIDER HL LOOP
HL*1**20*1~
HL - BILLING PROVIDER
PRV*BI*PXC*203BF0100Y~
PRV BILLING PROVIDER SPECIALTY INFORMATION
2010AA BILLING PROVIDER
NM1*85*2*BEN KILDARE SERVICE*****XX*9876543210~
NM1 BILLING PROVIDER NAME
N3*234 SEAWAY ST~
N3 BILLING PROVIDER ADDRESS
N4*MIAMI*FL*33111~
N4 BILLING PROVIDER LOCATION
REF*EI*587654321~
REF - BILLING PROVIDER TAX IDENTIFICATION
2010AB PAY-TO PROVIDER
NM1*87*2~
NM1 PAY-TO PROVIDER NAME
N3*2345 OCEAN BLVD~
N3 PAY-TO PROVIDER ADDRESS
N4*MIAMI*FL*33111~
N4 PAY-TO PROVIDER CITY
2000B SUBSCRIBER HL LOOP
HL*2*1*22*1~
HL - SUBSCRIBER
SBR*P**2222-SJ******CI~
SBR SUBSCRIBER INFORMATION
2010BA SUBSCRIBER
NM1*IL*1*SMITH*JANE****MI*JS00111223333~
NM1 SUBSCRIBER NAME
2010BB PAYER
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~
NM1 PAYER NAME
REF*G2*KA6663~
REF BILLING PROVIDER SECONDARY IDENTIFICATION
2000C PATIENT HL LOOP
HL*3*2*23*0~
HL - PATIENT
PAT*19~
PAT PATIENT INFORMATION
2010CA PATIENT
NM1*QC*1*SMITH*TED~
NM1 PATIENT NAME
N3*236 N MAIN ST~
N3 PATIENT ADDRESS
N4*MIAMI*FL*33413~
N4 PATIENT CITY/STATE/ZIP
DMG*D8*19730501*M~
DMG PATIENT DEMOGRAPHIC INFORMATION
2300 CLAIM
CLM*26463774*45***11:B:1*Y*A*Y*I**********08~
CLM CLAIM LEVEL INFORMATION
REF*D9*17312345600006351~
REF CLAIM IDENTIFICATION NUMBER FOR CLEARING HOUSES (Added by C.H.)
HI*BK:0340*BF:V7389~
HI HEALTH CARE DIAGNOSIS CODES
2400 SERVICE LINE
LX*1~
LX SERVICE LINE COUNTER
SV1*HC:99214*35*UN*1***2~
SV1 PROFESSIONAL SERVICE
2400 SERVICE LINE
LX*2~
LX SERVICE LINE COUNTER
SV1*HC:86663*10*UN*1***2~
SV1 PROFESSIONAL SERVICE
TRAILER
SE*33*0021~
SE TRANSACTION SET TRAILER