Section title: X12 EDI Examples
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ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X292

Example 1: Institutional Claim

Patient is the same person as the Subscriber. The Primary Payer is Medicare and the Secondary payer is State Teachers. The bill is a 141 Type of Bill.

PRIMARY PAYER SUBSCRIBER: John T Doe

SUBSCRIBER ADDRESS: 125 City Avenue, Centerville, PA 17111

SEX: M

DOB: 11/11/1926

MEDICARE INSURANCE ID#: 030005074A

PAYER ID #: 00435

PATIENT: Same as Primary Subscriber

DESTINATION PAYER: Medicare B

SUBMITTER: Jones Hospital

EDI#: 12345

RECEIVER: Medicare

EDI#: 00120

BILLING PROVIDER: Jones Hospital

NPI: 9876540809

TIN: 567891234

MEDICARE PROVIDER: #330127

ADDRESS: 225 Main Street Barkley Building, Centerville, PA 17111-1234

ATTENDING PHYSICIAN: John J Jones

UPIN #: B99937

PATIENT ACCOUNT NUMBER: 756048Q

PLACE OF SERVICE: Inpatient Hospital

Occurrence Codes and Dates:

  A1 11/11/26

  A2 11/01/91

  B1 11/11/26

  B2 01/01/87

Condition Codes: 09

Value Codes: A2 $15.31

PRINCIPAL DIAGNOSIS CODE: 366.9

SECONDARY DIAGNOSIS CODES:

  401.9

  794.31

NUMBER OF COVERED DAYS: 1

SERVICES:

INSTITUTIONAL SERVICES RENDERED:

REVENUE CODE: 0305 HCPCS Procedure Code: 85025 Unit: 1 Price $13.39

REVENUE CODE: 0730 HCPCS Procedure Code: 93005 Unit: 1 Price: $76.54

TOTAL CHARGES: $89.93

Transmission Explanation

HEADER

ST*837*987654*005010X292~

ST TRANSACTION SET HEADER

BHT*0019*00*0123*19960918*0932*CH~

BHT BEGINNING OF HIERARCHICAL TRANSACTION

1000A SUBMITTER NAME

NM1*41*2*JONES HOSPITAL*****46*12345~

NM1 SUBMITTER NAME

PER*IC*JANE DOE*TE*9005555555~

PER SUBMITTER EDI CONTACT INFORMATION

1000B RECEIVER NAME

NM1*40*2*MEDICARE*****46*00120~

NM1 RECEIVER NAME

2000A BILLING PROVIDER

HL*1**20*1~

HL BILLING PROVIDER HIERARCHICAL LEVEL

PRV*BI*PXC*203BA0200N~

PRV BILLING PROVIDER SPECIALTY

2010AA BILLING PROVIDER NAME

NM1*85*2*JONES HOSPITAL*****XX*9876540809~

NM1 BILLING PROVIDER NAME INCLUDING NATIONAL PROVIDER ID

N3*225 MAIN STREET BARKLEY BUILDING~

N3 BILLING PROVIDER ADDRESS

N4*CENTERVILLE*PA*171111234~

N4 BILLING PROVIDER LOCATION

REF*EI*567891234~

REF BILLING PROVIDER TAX IDENTIFICATION NUMBER

2000B SUBSCRIBER HL LOOP

HL*2*1*22*0~

HL SUBSCRIBER HIERARCHICAL LEVEL

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

SBR SUBSCRIBER INFORMATION

2010BA SUBSCRIBER NAME LOOP

NM1*IL*1*DOE*JOHN*T***MI*030005074A~

NM1 SUBSCRIBER NAME

N3*125 CITY AVENUE~

N3 SUBSCRIBER ADDRESS

N4*CENTERVILLE*PA*17111~

N4 SUBSCRIBER LOCATION

DMG*D8*19261111*M~

DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

2010BB PAYER NAME LOOP

NM1*PR*2*MEDICARE B*****PI*00435~

NM1 PAYER NAME

REF*G2*330127~

REF BILLING PROVIDER SECONDARY IDENTIFICATION

2300 CLAIM INFORMATION

CLM*756048Q*89.93***14:A:1**A*Y*Y**********08~

CLM CLAIM LEVEL INFORMATION

CL1*3**01~

CL1 INSTITUTIONAL CLAIM CODE

HI*BK:3669~

HI PRINCIPAL DIAGNOSIS CODES

HI*BF:4019*BF:79431~

HI OTHER DIAGNOSIS INFORMATION

HI*BH:A1:D8:19261111*BH:A2:D8:19911101*BH:B1:D8:19261111*BH:B2:D8:19870101~

HI OCCURRENCE INFORMATION

HI*BE:A2:::15.31~

HI VALUE INFORMATION

HI*BG:09~

HI CONDITION INFORMATION

2310A ATTENDING PROVIDER NAME

NM1*71*1*JONES*JOHN*J~

NM1 ATTENDING PROVIDER

REF*1G*B99937~

REF ATTENDING PROVIDER SECONDARY IDENTIFICATION

2400 SERVICE LINE

LX*1~

LX SERVICE LINE COUNTER

SV2*0305*HC:85025*13.39*UN*1~

SV2 INSTITUTIONAL SERVICE

2400 SERVICE LINE

LX*2~

LX SERVICE LINE COUNTER

SV2*0730*HC:93005*76.54*UN*1~

SV2 INSTITUTIONAL SERVICE

TRAILER

SE*33*987654~

SE TRANSACTION SET TRAILER