ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X292
Example 03: PPO Repriced Claim
Repriced claim being transmitted from a Regional PPO (Preferred Provider Organization) to a commercial health insurance company. The patient is a child of the subscriber. In this situation, the hospital 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: Jenny Jones
ADDRESS: 4512 West Avenue, Evansville, AZ 863030000
SEX: F
DATE OF BIRTH: 07/31/1969
EMPLOYER: DESSERT COMPANY, INC.
GROUP NUMBER: 46522567AW
MEMBER ID: 345U8423H
PATIENT: Joy Jones
ADDRESS: 4512 West Avenue, Evansville, AZ 863030000
SEX: F
DATE OF BIRTH: 08/20/1998
PATIENT ACCOUNT NUMBER: 456DFH43
OTHER INSURANCE: Other Coverage Company
PAYER ID: 534524
OTHER INSURED NAME: George Jones
OTHER GROUP NAME: T&T Plumbing Company
OTHER INSURED DATE OF BIRTH: 01/22/1970
OTHER INSURED MEMBER ID: 56454566
SUBMITTER: Regional PPO Network
SUBMITTER ID: 123456789
TAX ID: 123456789
RECEIVER: Local Insurance Company
RECEIVER ID: 54334452
DESTINATION PAYER: Local Insurance Company
PAYER ID NUMBER: 7452723
BILLING PROVIDER: Good Health Hospital
ADDRESS: 592 North Elm Street, Edgewood, AZ 86001-5590
NATIONAL PROVIDER ID (NPI): 1257234346
TAX IDENTIFICATION NUMBER (TIN): 344-23-2321
ATTENDING PROVIDER: Simon Johnson
NATIONAL PROVIDER ID (NPI): 5544332211
TOTAL CLAIM CHARGES: $237.5
TOTAL CLAIM REPRICED AMOUNT: $182.88
TOTAL CLAIM SAVINGS AMOUNT: $54.62
TIN FOR THE REPRICING ORGANIZATION: 332211445
SERVICE LINE 1 REPRICING INFORMATION:
TOTAL SERVICE LINE CHARGES: $178.00
TOTAL REPRICED AMOUNT: $137.06
SAVINGS AMOUNT: $40.94
TIN FOR THE REPRICING ORGANIZATION: 332211445
SERVICE LINE 2 REPRICING INFORMATION:
TOTAL SERVICE LINE CHARGES: $59.50
TOTAL REPRICED AMOUNT: $45.82
SAVINGS AMOUNT: $13.68
TIN FOR THE REPRICING ORGANIZATION: 332211445
DATE OF SERVICE: 07/06/05
Transmission Explanation
HEADER
ST*837*1002*005010X292~
ST TRANSACTION SET HEADER
BHT*0019*00*1002*20050721*09460000*CH~
BHT BEGINNING OF HIERARCHICAL TRANSACTION
1000A SUBMITTER NAME
NM1*41*2*REGIONAL PPO NETWORK*****46*123456789~
NM1 SUBMITTER NAME
PER*IC*SUBMITTER CONTACT INFO*TE*8001231234~
PER SUBMITTER EDI CONTACT INFORMATION
1000B RECEIVER NAME
NM1*40*2*LOCAL INSURANCE COMPANY*****46*54334452~
NM1 RECEIVER NAME
2000A BILLING PROVIDER
HL*1**20*1~
HL BILLING PROVIDER HIERARCHICAL LEVEL
2010AA BILLING PROVIDER NAME
NM1*85*2*GOOD HEALTH HOSPITAL*****XX*1257234346~
NM1 BILLING PROVIDER NAME INCLUDING NATIONAL PROVIDER ID
N3*592 NORTH ELM STREET~
N3 BILLING PROVIDER ADDRESS
N4*EDGEWOOD*AZ*860015590~
N4 BILLING PROVIDER LOCATION
REF*EI*344232321~
REF BILLING PROVIDER TAX IDENTIFICATION NUMBER
2000B SUBSCRIBER HL LOOP
HL*2*1*22*1~
HL SUBSCRIBER HIERARCHICAL LEVEL
SBR*P**46522567AW******CI~
SBR SUBSCRIBER INFORMATION
2010BA SUBSCRIBER NAME LOOP
NM1*IL*1*JONES*JENNY****MI*345U8423H~
NM1 SUBSCRIBER NAME
2010BB PAYER NAME LOOP
NM1*PR*2*LOCAL INSURANCE COMPANY*****PI*7452723~
NM1 PAYER NAME
2000C PATIENT HL LOOP
HL*3*2*23*0~
HL PATIENT HIERARCHICAL LEVEL
PAT*19~
PAT PATIENT INFORMATION
2010CA PATIENT NAME
NM1*QC*1*JONES*JOY~
NM1 PATIENT NAME
N3*4512 WEST AVENUE~
N3 PATIENT STREET ADDRESS
N4*EVANSVILLE*AZ*863030000~
N4 PATIENT LOCATION
DMG*D8*19980820*F~
DMG PATIENT DEMOGRAPHIC INFORMATION
2300 CLAIM INFORMATION
CLM*456DFH43*237.5***13:A:1**A*Y*Y**********08~
CLM CLAIM LEVEL INFORMATION
CL1**2*01~
CL1 INSTITUTIONAL CLAIM CODE
REF*9A*09459034092~
REF REPRICED CLAIM NUMBER
REF*D9*04566877634343456~
REF CLEARING HOUSE CLAIM NUMBER (ASSIGNED BY THE CLEARING HOUSE WHEN TRANSMITTING TO THE REPRICER)
HI*BK:38181~
HI HEALTH CARE PRINCIPAL DIAGNOSIS CODES
HI*BF:38900~
HI OTHER DIAGNOSIS INFORMATION
HI*BH:11:D8:20050706~
HI OCCURRENCE INFORMATION
HCP*03*182.88*54.62*123456789~
HCP HEALTH CARE PRICING - REPRICING INFORMATION
2310A ATTENDING PROVIDER NAME
NM1*71*1*JOHNSON*SIMON****XX*5544332211~
NM1 ATTENDING PROVIDER
2400 SERVICE LINE
LX*1~
LX SERVICE LINE COUNTER
SV2*0471*HC:92557*178*UN*1~
SV2 INSTITUTIONAL SERVICE
HCP*03*137.06*40.94~
HCP HEALTH CARE PRICING - REPRICING INFORMATION
2400 SERVICE LINE
LX*2~
LX SERVICE LINE COUNTER
SV2*0471*HC:92567*59.5*UN*1~
SV2 INSTITUTIONAL SERVICE
HCP*03*45.82*13.68~
HCP HEALTH CARE PRICING - REPRICING INFORMATION
TRAILER
SE*36*1002~
SE TRANSACTION SET TRAILER