ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X291
Example 07: Anesthesia
Patient is the same as the subscriber. Payer is Medicare. Predetermination request is a direct submission.
SUBSCRIBER/PATIENT: Margaret Jones
ADDRESS: 123 Rainbow Road, Nashville, TN 37232
TELEPHONE: 615-555-1212
SEX: F
DOB: 03/03/1974
EMPLOYER: ACME Inc.
SUBSCRIBER #: 123456789A
SECONDARY COVERAGE
DESTINATION PAYER: ABC Payer
PAYER ADDRESS: P.O. Box 1465, Nashville, TN, 37232
PAYER ORGANIZATION ID: 05440
RECEIVER: ABC Payer
EDI #: 05440
BILLING PROVIDER/SENDER: Provider Medical Group
ADDRESS: 1234 West End Ave, Nashville, TN, 37232
NPI#: 2366554859
TIN: 756473826
EDI #: N305
CONTACT PERSON AND PHONE NUMBER: Nina, 615-555-1212 ext.911
RENDERING PROVIDER: Dr. Jacob E. Townsend/Anesthesiologist
NPI: 5678912345
MEDICARE PROVIDER ID#: 9741234
PLACE OF SERVICE: Provider OP Hospital
PLACE OF SERVICE ADDRESS: 345 Main Drive, Nashville, TN, 37232
PLACE OF SERVICE ID#: 43294867
PATIENT ACCOUNT NUMBER: 543211230
CASE: Laser Eye Surgery.
VISIT: DOS - For predetermination requests, the current date is assumed.
POS=Outpatient Hospital
SERVICES: Anesthesia for the Laser Eye Surgery
CHARGES: Anesthesia, 61 minutes = $827.00
CONCURRENCY: 2 cases
PHYSICAL STATUS: Normal
PATIENT CONTROL #: 153829140
MEDICAL RECORD ID #: 006653794
TOTAL CHARGES: $827.00
ELECTRONIC ROUTE: Billing Provider (sender) to ABC PAYER direct
Transmission Explanation
HEADER
ST*837*0001*005010X291~
ST TRANSACTION SET HEADER
BHT*0019*00*0123*20050117*1023*CH~
BHT BEGINNING OF HIERARCHICAL TRANSACTION
1000A SUBMITTER
NM1*41*2*PROVIDER MEDICAL GROUP*****46*N305~
NM1 SUBMITTER
PER*IC*NINA*TE*6155551212*EX*911~
PER SUBMITTER EDI CONTACT INFORMATION
1000B RECEIVER
NM1*40*2*ABC PAYER*****46*05440~
NM1 RECEIVER NAME
2000A BILLING PROVIDER HL LOOP
HL*1**20*1~
HL - BILLING PROVIDER
2010AA BILLING PROVIDER
NM1*85*2*PROVIDER MEDICAL GROUP*****XX*2366554859~
NM1 BILLING PROVIDER NAME
N3*1234 WEST END AVE~
N3 BILLING PROVIDER ADDRESS
N4*NASHVILLE*TN*37232~
N4 BILLING PROVIDER CITY/STATE/ZIP
REF*EI*756473826~
REF BILLING PROIVDER TAX IDENTIFIER
2000B SUBSCRIBER HL LOOP
HL*2*1*22*0~
HL - SUBSCRIBER
SBR*P*18*******MB~
SBR SUBSCRIBER INFORMATION
2010BA SUBSCRIBER
NM1*IL*1*JONES*MARGARET****MI*123456789A~
NM1 SUBSCRIBER NAME
N3*123 RAINBOW ROAD~
N3 SUBSCRIBER STREET ADDRESS
N4*NASHVILLE*TN*37232~
N4 SUBSCRIBER CITY/STATE/ZIP
DMG*D8*19740303*F~
DMG SUBSCRIBER DEMOGRAPHIC INFORMATION
2010BB SUBSCRIBER / PAYER
NM1*PR*2*ABC PAYER*****PI*05440~
NM1 PAYER NAME
2300 CLAIM
CLM*153829140*827***22:B:1*Y*A*Y*Y**********08~
CLM CLAIM LEVEL INFORMATION
HI*BK:36616~
HI HEALTH CARE DIAGNOSIS CODES
2310B RENDERING PROVIDER
NM1*82*1*TOWNSEND*JACOB*E***XX*5678912345~
NM1 RENDERING PROVIDER NAME
PRV*PE*PXC*207L00000X~
PRV RENDERING PROVIDER TAXONOMY INFORMATION
2310C SERVICE FACILITY LOCATION
NM1*77*2*PROVIDER OP HOSP*****XX*432198765~
NM1 SERVICE FACILITY LOCATION
N3*345 MAIN DRIVE~
N3 SERVICE FACILITY LOCATION
N4*NASHVILLE*TN*37232~
N4 SERVICE FACILITY LOCATION CITY/STATE/ZIP
2400 SERVICE LINE
LX*1~
LX SERVICE LINE COUNTER
SV1*HC:00142:QK:QS:P1*827*MJ*61***1~
SV1 PROFESSIONAL SERVICE
TRAILER
SE*27*0001~
SE TRANSACTION SET TRAILER