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

Example 6: Wheelchair

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

SUBSCRIBER/PATIENT: James Smith

ADDRESS: 12 Main Street, Frankfort, IN 46209

SEX: M

DOB: 10/23/1920

HIC#: 987-65-4321A

DESTINATION PAYER: DMERC Carrier

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

EDI #: 99999

BILLING PROVIDER/SENDER: XYZ Wheelchairs Inc

ADDRESS: 1440 North Street, Lafayette, IN 47904

TIN: 123567989

EDI #: ABC55

NPI#: 7778889999

DMERC Provider #: 0426960001

CONTACT PERSON AND PHONE NUMBER: Jane Doe, 222-555-1111

EMAIL: HELPDESK@WHEELCHAIR.COM

ORDERING PROVIDER: Dr. Randall Wilson

ADDRESS: 1226 West Railroad St, Lafayette, IN 47905

NPI#: 1111155555

UPIN#: M12345

CONTACT PERSON AND PHONE NUMBER: Lee, 765-297-7999

PATIENT ACCOUNT NUMBER: SMI123

CASE: Paralysis & CVA

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

POS=Home

SERVICES: Standard wheelchair rental for $75.00

Transmission Explanation

HEADER

ST*837*112233*005010X291~

ST TRANSACTION SET HEADER

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

BHT BEGINNING OF HIERARCHICAL TRANSACTION

1000A SUBMITTER

NM1*41*2*XYZ WHEELCHAIRS INC*****46*ABC55~

NM1 SUBMITTER

PER*IC*JANE*TE*2225551111~

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*XYZ WHEELCHAIR INC*****XX*7778889999~

NM1 BILLING PROVIDER NAME

N3*1440 NORTH STREET~

N3 BILLING PROVIDER ADDRESS

N4*LAFAYETTE*IN*47904~

N4 BILLING PROVIDER LOCATION

REF*EI*123567989~

REF BILLING PROIVDER TAX IDENTIFIER

REF*1G*0426960001~

REF BILLING PROIVDER SECONDARY IDENTIFIER

2000B SUBSCRIBER HL LOOP

HL*2*1*22*0~

HL SUBSCRIBER

SBR*P*18*******MB~

SBR SUBSCRIBER INFORMATION

PAT*******01*155~

PAT PATIENT INFORMATION

2010BA SUBSCRIBER

NM1*IL*1*SMITH*JAMES****MI*987654321A~

NM1 SUBSCRIBER NAME

N3*12 MAIN ST~

N3 SUBSCRIBER ADDRESS

N4*FRANKFORT*IN*46209~

N4 SUBSCRIBER CITY

DMG*D8*19201023*M~

DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

2010BB SUBSCRIBER / PAYER

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

NM1 PAYER NAME

2300 CLAIM

CLM*SMI123*75***12:B:1*Y*A*Y*Y**********08~

CLM CLAIM LEVEL INFORMATION

HI*BK:436*BF:3449~

HI HEALTH CARE DIAGNOSIS CODES

2400 SERVICE LINE

LX*1~

LX SERVICE LINE COUNTER

SV1*HC:K0001:RR:KH:BR*75*UN*1***1:2~

SV1 PROFESSIONAL SERVICE

PWK*CT*AD~

PWK CLAIM SUPPLEMENTAL INFORMATION

CR3*I*MO*99~

CR3 DURABLE MEDICAL EQUIPMENT CERTIFICATION

DTP*463*D8*20040321~

DTP BEGIN THERAPY DATE

DTP*461*D8*20050321~

DTP LAST CERTIFICATION DATE

MEA*TR*HT*70~

MEA TEST RESULT

2420E ORDERING PROVIDER

NM1*DK*1*WILSON*RANDALL****XX*1111155555~

NM1 ORDERING PROVIDER NAME

N3*1226 WEST RAILROAD STREET~

N3 ORDERING PROVIDER ADDRESS

N4*LAFAYETTE*IN*47905~

N4 ORDERING PROVIDER CITY/STATE/ZIP CODE

PER*IC*LEE*TE*7659259999~

PER ORDERING PROVIDER CONTACT INFORMATION

2440 FORM IDENTIFICATION CODE

LQ*UT*02.03B~

LQ FORM IDENTIFICATION CODE

FRM*1*Y~

FRM SUPPORTING DOCUMENTATION

FRM*2*N~

FRM SUPPORTING DOCUMENTATION

FRM*3*N~

FRM SUPPORTING DOCUMENTATION

FRM*4*N~

FRM SUPPORTING DOCUMENTATION

FRM*5**8~

FRM SUPPORTING DOCUMENTATION

FRM*8*N~

FRM SUPPORTING DOCUMENTATION

FRM*9*Y~

FRM SUPPORTING DOCUMENTATION

TRAILER

SE*41*112233~

SE TRANSACTION SET TRAILER