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

Example 3: 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