Section title: X12 EDI Examples
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ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X291

Example 5: Oxygen

Patient is the same person as the Subscriber. Claim is submitted by provider directly and the Payer is Medicare DMERC.

SUBSCRIBER/PATIENT: Terry Smith

ADDRESS: 121 South Street, Richmond, IN 46236

SEX: F

DOB: 01/05/38

HIC#: 111-22-2333A

DESTINATION PAYER: DMERC Carrier

PAYOR ADDRESS: 926 W Angel Rd, Richmond, IN 46236

EDI #: 99999

BILLING PROVIDER/SENDER: Oxygen Supply Company

ADDRESS: 1800 East Ridge Drive, Richmond, IN 46224

TIN: 389999999

EDI #: ABC11111

NPI#: 9992233334

DMERC Provider #: 099999999

CONTACT PERSON AND PHONE NUMBER: Bonnie, 812-555-1111

EMAIL: HELPDESK@OXYGEN.COM

ORDERING PROVIDER: Dr. Larry Wilson

ADDRESS: 1212 North Meridian, Richmond, IN 46223

NPI#: 5555511111

UPIN#: X99999

PHONE NUMBER: 555-444-6666

PATIENT ACCOUNT NUMBER: R03996273 #01

CASE: Chronic Airway Obstruction

SERVICE: DOS - For predetermination requests, the current date is assumed.

POS=Home

SERVICES: Oxygen concentrator and Portable gaseous O2

CHARGES: Oxygen concentrator = $461.10, Portable gaseous oxygen = $59.14

TOTAL CHARGES: $520.24

Transmission Explanation

HEADER

ST*837*0001*005010X291~

ST TRANSACTION SET HEADER

BHT*0019*00*16*20050326*1036*CH~

BHT BEGINNING OF HIERARCHICAL TRANSACTION

1000A SUBMITTER

NM1*41*2*OXYGEN SUPPLY COMPANY*****46*ABC11111~

NM1 SUBMITTER

PER*IC*BONNIE*TE*8125551111*EM*HELPDESK@OXYGEN.COM~

PER SUBMITTER EDI CONTACT INFORMATION

1000B RECEIVER

NM1*40*2*DMERC CARRIER*****46*99999~

NM1 RECEIVER NAME

2000A BILLING PROVIDER HL LOOP

HL*1**20*1~

HL - BILLING PROVIDER

2010AA BILLING PROVIDER

NM1*85*2*OXYGEN SUPPLY COMPANY*****XX*9992233334~

NM1 BILLING PROVIDER NAME

N3*1800 EAST RIDGE DRIVE~

N3 BILLING PROVIDER ADDRESS

N4*RICHMOND*IN*46224~

N4 BILLING PROVIDER LOCATION

REF*EI*389999999~

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*SMITH*TERRY****MI*111222333A~

NM1 SUBSCRIBER NAME

N3*121 SOUTH ST~

N3 SUBSCRIBER ADDRESS

N4*RICHMOND*IN*46236~

N4 SUBSCRIBER CITY

DMG*D8*19380105*F~

DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

2010BB SUBSCRIBER / PAYER

NM1*PR*2*DMERC CARRIER*****PI*99999~

NM1 PAYER NAME

2300 CLAIM

CLM*R03996273 #01*520.24***11:B:1*Y*A*Y*Y**********08~

CLM CLAIM LEVEL INFORMATION

HI*BK:496*BF:51881*BF:2859~

HI HEALTH CARE DIAGNOSIS CODES

2400 SERVICE LINE

LX*1~

LX SERVICE LINE COUNTER

SV1*HC:E1390:RR*461.1*UN*1***1:2~

SV1 PROFESSIONAL SERVICE

PWK*CT*AD~

PWK DURABLE MEDICAL EQUIPMENT CERTIFICATE OF MEDICAL NECESSITY INDICATOR

CR3*R*MO*99~

CR3 DURABLE MEDICAL EQUIPMENT CERTIFICATION

DTP*607*D8*20050321~

DTP CERTIFICATION REVISION/RECERTIFICATION DATE

DTP*463*D8*20040321~

DTP BEGIN THERAPY DATE

DTP*461*D8*20050321~

DTP LAST CERTIFICATION DATE

2420E ORDERING PROVIDER

NM1*DK*1*WILSON*LARRY****XX*5555511111~

NM1 ORDERING PROVIDER NAME

N3*1212 NORTH MERIDIAN~

N3 ORDERING PROVIDER ADDRESS

N4*RICHMOND*IN*46223~

N4 ORDERING PROVIDER CITY/STATE/ZIP CODE

REF*1G*X99999~

REF ORDERING PROVIDER INFORMATION

PER*IC*LEE*TE*5554446666~

PER ORDERING PROVIDER CONTACT INFORMATION

2440 FORM IDENTIFICATION CODE

LQ*UT*04.03~

LQ FORM IDENTIFICATION CODE

FRM*1A**056~

FRM SUPPORTING DOCUMENTATION

FRM*1C**20050228~

FRM SUPPORTING DOCUMENTATION

FRM*2**1~

FRM SUPPORTING DOCUMENTATION

FRM*3**1~

FRM SUPPORTING DOCUMENTATION

FRM*4*Y~

FRM SUPPORTING DOCUMENTATION

FRM*5**2~

FRM SUPPORTING DOCUMENTATION

FRM*7*Y~

FRM SUPPORTING DOCUMENTATION

FRM*8*N~

FRM SUPPORTING DOCUMENTATION

FRM*9*Y~

FRM SUPPORTING DOCUMENTATION

2400 SERVICE LINE

LX*2~

LX SERVICE LINE COUNTER

SV1*HC:E0431:RR*59.14*UN*1***1:2~

SV1 PROFESSIONAL SERVICE

PWK*CT*AD~

PWK DURABLE MEDICAL EQUIPMENT CERTIFICATE OF MEDICAL NECESSITY INDICATOR

CR3*R*MO*99~

CR3 DURABLE MEDICAL EQUIPMENT CERTIFICATION

DTP*607*D8*20050321~

DTP CERTIFICATION REVISION/RECERTIFICATION DATE

DTP*463*D8*20040321~

DTP BEGIN THERAPY DATE

DTP*461*D8*20050321~

DTP LAST CERTIFICATION DATE

2420E ORDERING PROVIDER

NM1*DK*1*WILSON*LARRY****XX*5555511111~

NM1 ORDERING PROVIDER NAME

N3*1212 NORTH MERIDIAN~

N3 ORDERING PROVIDER ADDRESS

N4*RICHMOND*IN*46223~

N4 ORDERING PROVIDER CITY/STATE/ZIP CODE

REF*1G*X99999~

REF ORDERING PROVIDER INFORMATION

PER*IC*LEE*TE*5554446666~

PER ORDERING PROVIDER CONTACT INFORMATION

2440 FORM IDENTIFICATION CODE

LQ*UT*04.03~

LQ FORM IDENTIFICATION CODE

FRM*1A**056~

FRM SUPPORTING DOCUMENTATION

FRM*1C**20050228~

FRM SUPPORTING DOCUMENTATION

FRM*2**1~

FRM SUPPORTING DOCUMENTATION

FRM*3**1~

FRM SUPPORTING DOCUMENTATION

FRM*4*Y~

FRM SUPPORTING DOCUMENTATION

FRM*5**2~

FRM SUPPORTING DOCUMENTATION

FRM*7*Y~

FRM SUPPORTING DOCUMENTATION

FRM*8*N~

FRM SUPPORTING DOCUMENTATION

FRM*9*Y~

FRM SUPPORTING DOCUMENTATION

TRAILER

SE*64*0001~

SE TRANSACTION SET TRAILER