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

Example 2: Two Claims for the Same Provider

This example combines two claims for the same provider.

DESTINATION PAYER: TRICARE

PAYER ID: 99999

BILLING PROVIDER: Jones Hospital

BILLING PROVIDER ADDRESS: 225 MAIN STREET, ANYWHERE, PA, 17111-1234

BILLING PROVIDER SPECIALTY: 282N00000X

BILLING PROVIDER EMPLOYER ID: 123456789

BILLING PROVIDER NPI: 1234567890

SUBMITTER ETIN: 12345

SUBMITTER CONTACT: Jane Doe

SUBMITTER CONTACT TELEPHONE: (111)222-3333

CLAIM #1:

SUBSCRIBER: John T. Doe

MEMBER ID: 030005074

SUBSCRIBER ADDRESS: 125 City Avenue, Anywhere, PA, 17111

DOB: November 11, 1968

SEX: M

PATIENT ACCOUNT #: 756048Q

CLAIM AMOUNT: 89.95

TYPE OF BILL: 131

PRINCIPAL DIAGNOSIS: 366.9

OTHER DIAGNOSIS: 401.9, 794.31

ATTENDING PHYSICIAN: John J. Jones

ATTENDING PHYSICIAN NPI: 1122334455

UPIN: U12345

PROCEDURES:

Rev code: 0305 HCPCS: 85025 Billed Amt: 13.39 Units: 1.

Rev code: 0730 HCPCS: 93010 Billed Amt: 76.56 Units: 3.

CLAIM #2:

SUBSCRIBER: Joe Smith

MEMBER ID: 123405074

SUBSCRIBER ADDRESS: 5 Main Street, Anywhere, PA, 17111

DOB: December 12, 1962

SEX: M

PATIENT ACCOUNT #: 756049Q

CLAIM AMOUNT: 50.00

TYPE OF BILL: 131

PRINCIPAL DIAGNOSIS: 300.00

ATTENDING PHYSICIAN: Judy J. Jones

NPI: 9999999999

PROVIDER SPECIALTY: 363LP0200N

PROCEDURES:

Rev code: 0300 HCPCS: 85087 Billed Amt: 50.00 Units: 1.

Transmission Explanation

HEADER

ST*837*987654*005010X292~

ST TRANSACTION SET HEADER

BHT*0019*00*0123*20050630*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*1112223333~

PER SUBMITTER EDI CONTACT INFORMATION

1000B RECEIVER NAME

NM1*40*2*TRICARE*****46*99999~

NM1 RECEIVER NAME

2000A BILLING PROVIDER

HL*1**20*1~

HL BILLING PROVIDER HIERARCHICAL LEVEL

PRV*BI*PXC*282N00000X~

PRV BILLING PROVIDER SPECIALTY

2010AA BILLING PROVIDER NAME

NM1*85*2*JONES HOSPITAL*****XX*1234567890~

NM1 BILLING PROVIDER NAME INCLUDING NATIONAL PROVIDER ID

N3*225 MAIN STREET~

N3 BILLING PROVIDER ADDRESS

N4*ANYWHERE*PA*171111234~

N4 BILLING PROVIDER LOCATION

REF*EI*123456789~

REF BILLING PROVIDER TAX IDENTIFICATION NUMBER

2000B SUBSCRIBER HL LOOP

HL*2*1*22*0~

HL SUBSCRIBER HIERARCHICAL LEVEL

SBR*P*18*******CH~

SBR SUBSCRIBER INFORMATION

2010BA SUBSCRIBER NAME LOOP

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

NM1 SUBSCRIBER NAME

N3*125 CITY AVENUE~

N3 SUBSCRIBER ADDRESS

N4*CENTERVILLE*PA*17111~

N4 SUBSCRIBER LOCATION

DMG*D8*19681111*M~

DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

2010BB PAYER NAME LOOP

NM1*PR*2*TRICARE*****PI*99999~

NM1 PAYER NAME

2300 CLAIM INFORMATION

CLM*756048Q*89.95***13:A:1**C*Y*Y**********08~

CLM CLAIM LEVEL INFORMATION

CL1***01~

CL1 INSTITUTIONAL CLAIM CODE

HI*BK:3669~

HI PRINCIPAL DIAGNOSIS CODES

HI*BF:4019*BF:79431~

HI OTHER DIAGNOSIS INFORMATION

2310A ATTENDING PROVIDER NAME

NM1*71*1*JONES*JOHN*J***XX*1122334455~

NM1 ATTENDING PROVIDER

REF*1G*U12345~

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:93010*76.56*UN*3~

SV2 INSTITUTIONAL SERVICE

2000B SUBSCRIBER HL LOOP

HL*3*1*22*0~

HL SUBSCRIBER HIERARCHICAL LEVEL

SBR*P*18*******CH~

SBR SUBSCRIBER INFORMATION

2010BA SUBSCRIBER NAME LOOP

NM1*IL*1*SMITH*JOE****MI*123405074~

NM1 SUBSCRIBER NAME

N3*5 MAIN STREET~

N3 SUBSCRIBER ADDRESS

N4*ANYWHERE*PA*17111~

N4 SUBSCRIBER LOCATION

DMG*D8*19621210*M~

DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

2010BB PAYER NAME LOOP

NM1*PR*2*TRICARE*****PI*99999~

NM1 PAYER NAME

2300 CLAIM INFORMATION

CLM*756048Q*50***13:A:1**C*Y*Y**********08~

CLM CLAIM LEVEL INFORMATION

CL1***01~

CL1 INSTITUTIONAL CLAIM CODE

HI*BK:30000~

HI PRINCIPAL DIAGNOSIS CODES

2310A ATTENDING PROVIDER NAME

NM1*71*1*JONES*JUDY*J***XX*9999999999~

NM1 ATTENDING PROVIDER

PRV*AT*PXC*363LP0200N~

PRV - ATTENDING PROVIDER SPECIALTY INFORMATION

2400 SERVICE LINE

LX*1~

LX SERVICE LINE COUNTER

SV2*0300*HC:85087*50*UN*1~

SV2 INSTITUTIONAL SERVICE

TRAILER

SE*45*987654~

SE TRANSACTION SET TRAILER