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

Example 9: PPO Repriced Claim

Repriced claim being transmitted from a Regional PPO (Preferred Provider Organization) to a commercial health insurance company. The patient is the same person as the subscriber. In this situation, the provider has sent the claim to a clearinghouse, which then forwarded the claim to the repricer; the claim has been repriced and is now being forwarded to the appropriate payer for payment.

SUBSCRIBER/PATIENT: Diamond D. Ring

ADDRESS: 123 Example Drive, Indianapolis, IN 462290000

SEX: F

DATE OF BIRTH: 12/29/1940

EMPLOYER: COMPANY, INC.

GROUP NUMBER: 123XYZ

MEMBER ID: 00124A089

PATIENT ACCOUNT NUMBER: ABC123-RI

SUBMITTER: Regional PPO Network

SUBMITTER ID: 123456789

RECEIVER: Extra Healthy Insurance

RECEIVER ID: 112244

DESTINATION PAYER: Extra Healthy Insurance

PAYER ID NUMBER: 12345

BILLING PROVIDER: HAPPY DOCTORS GROUP PRACTICE

ADDRESS: P O BOX 123, Fort Wayne, IN 462540000

NATIONAL PROVIDER ID (NPI): 1234567890

TAX IDENTIFICATION NUMBER (TIN): 555-51-2345

REFERRING PROVIDER: John Doe

NATIONAL PROVIDER ID (NPI): 9988776655

RENDERING PROVIDER: Susan B. Anthony

NATIONAL PROVIDER ID (NPI): 1122334455

TOTAL CLAIM CHARGES: $28.75

TOTAL CLAIM REPRICED AMOUNT: $26.75

TOTAL CLAIM SAVINGS AMOUNT: $2.00

SERVICE LINE 1 REPRICING INFORMATION:

TOTAL SERVICE LINE CHARGES: $25.00

TOTAL REPRICED AMOUNT: $23.75

SAVINGS AMOUNT: $1.25

TIN FOR THE REPRICING ORGANIZATION: 908231234

DATE OF SERVICE: For predetermination requests, the current date is assumed.

SERVICE LINE 2 REPRICING INFORMATION:

TOTAL SERVICE LINE CHARGES: $3.75

TOTAL REPRICED AMOUNT: $3

SAVINGS AMOUNT: $.75

TIN FOR THE REPRICING ORGANIZATION: 908231234

DATE OF SERVICE: For predetermination requests, the current date is assumed.

Transmission Explanation

HEADER

ST*837*1002*005010X291~

ST TRANSACTION SET HEADER

BHT*0019*00*1002*20050620*09460000*CH~

BHT BEGINNING OF HIERARCHICAL TRANSACTION

1000A SUBMITTER

NM1*41*2*REGIONAL PPO NETWORK*****46*123456789~

NM1 SUBMITTER

PER*IC*SUBMITTER CONTACT INFO*TE*8001231234~

PER SUBMITTER EDI CONTACT INFORMATION

1000B RECEIVER

NM1*40*2*EXTRA HEALTHY INSURANCE*****46*112244~

NM1 RECEIVER NAME

2000A BILLING PROVIDER

HL*1**20*1~

HL BILLING PROVIDER HIERARCHICAL LEVEL

2010AA BILLING PROVIDER NAME

NM1*85*2*HAPPY DOCTORS GROUP PRACTICE*****XX*1234567890~

NM1 BILLING PROVIDER NAME INCLUDING NATIONAL PROVIDER ID

N3*P O BOX 123~

N3 BILLING PROVIDER ADDRESS

N4*FORT WAYNE*IN*462540000~

N4 BILLING PROVIDER LOCATION

REF*EI*555512345~

REF BILLING PROVIDER TAX IDENTIFICATION NUMBER

PER*IC*SUE BILLINGSWORTH*TE*8881231234~

PER BILLING PROVIDER CONTACT INFORMATION

2000B SUBSCRIBER HL LOOP

HL*2*1*22*0~

HL SUBSCRIBER HIERARCHICAL LEVEL

SBR*P*18*123XYZ******CI~

SBR SUBSCRIBER INFORMATION

2010BA SUBSCRIBER NAME LOOP

NM1*IL*1*RING*DIAMOND*D***MI*00124A089~

NM1 SUBSCRIBER NAME

N3*123 EXAMPLE DRIVE~

N3 SUBSCRIBER ADDRESS

N4*INDIANAPOLIS*IN*462290000~

N4 SUBSCRIBER LOCATION

DMG*D8*19401229*F~

DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

2010BB PAYER NAME LOOP

NM1*PR*2*EXTRA HEALTHY INSURANCE*****PI*12345~

NM1 PAYER NAME

2300 CLAIM

CLM*ABC123-RI*28.75***11>B>1*Y*A*Y*Y*P*********08~

CLM CLAIM LEVEL INFORMATION

REF*9A*0902352342~

REF REPRICED CLAIM NUMBER

REF*D9*061505501749388~

REF CLEARING HOUSE CLAIM NUMBER (ASSIGNED BY THE CLEARING HOUSE WHEN TRANSMITTING TO THE REPRICER)

HI*BK:496*BF:25000~

HI HEALTH CARE DIAGNOSIS CODES

HCP*03*26.75*2*908231234~

HCP HEALTH CARE PRICING - REPRICING INFORMATION

2310A REFERRING PROVIDER

NM1*DN*1*DOE*JOHN****XX*9988776655~

NM1 REFERRING PROVIDER

2310B RENDERING PROVIDER

NM1*82*1*ANTHONY*SUSAN*B***XX*1122334455~

NM1 RENDERING PROVIDER

2310D SERVICE FACILITY LOCATION

NM1*77*2*HAPPY DOCTORS GROUP~

NM1 SERVICE FACILITY LOCATION

N3*123 FEEL GOOD ROAD~

N3 FACILITY ADDRESS

N4*WASHINGTON*IN*475010000~

N4 FACILITY LOCATION

2400 SERVICE LINE

LX*1~

LX SERVICE LINE COUNTER

SV1*HC:E0570:RR*25*UN*1***1:2~

SV1 PROFESSIONAL SERVICE

HCP*03*23.75*1.25*908231234~

HCP HEALTH CARE PRICING - REPRICING INFORMATION

2400 SERVICE LINE

LX*2~

LX SERVICE LINE COUNTER

SV1*HC:A7003:NU*3.75*UN*1***1~

SV1 PROFESSIONAL SERVICE

HCP*03*3*.75*908231234~

HCP HEALTH CARE PRICING - REPRICING INFORMATION

TRAILER

SE*35*1002~

SE TRANSACTION SET TRAILER