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

Example 4: Out of Network Repriced Claim

An out of network claim is being transmitted from a Regional PPO (Preferred Provider Organization) to a commercial health insurance company.The patient and the subscriber are the same. In this situation, the hospital has sent the claim to a clearinghouse, which then forwarded the claim to the repricer; the claim has been determined to be out of network and is now being forwarded to the appropriate payer for payment.

PATIENT/SUBSCRIBER: JAMES A SMITH

ADDRESS: 934 North Street, Columbus, OH 432150000

SEX: M

DATE OF BIRTH: 10/15/1962

EMPLOYER: TREE TRIMMING SERVICE

GROUP NUMBER: 34561W

MEMBER ID: 34902390F

PATIENT CONTROL NUMBER: W392-49141

SUBMITTER: Regional PPO Network

SUBMITTER ID: 123456789

RECEIVER: Conservative Insurance

RECEIVER ID: 000110002

DESTINATION PAYER: Conservative Insurance

PAYER ID NUMBER: 00123

BILLING PROVIDER: LOCAL HOSPITAL

ADDRESS: 3423 Small Street, Columbus, OH 432150000

NATIONAL PROVIDER ID (NPI): 1122334455

TAX IDENTIFICATION NUMBER (TIN): 111-00-2222

RENDERING PROVIDER: Dawn Rivers

NATIONAL PROVIDER ID (NPI): 2244224455

REPRICING INFORMATION:

TOTAL CHARGES: $14.84

TOTAL REPRICED AMOUNT: $0

SAVINGS AMOUNT: $0

TIN FOR THE REPRICING ORGANIZATION: 333001234

Transmission Explanation

HEADER

ST*837*1024*005010X292~

ST TRANSACTION SET HEADER

BHT*0019*00*1024*20050711*1335*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*CONSERVATIVE INSURANCE*****46*000110002~

NM1 RECEIVER NAME

2000A BILLING PROVIDER

HL*1**20*1~

HL BILLING PROVIDER HIERARCHICAL LEVEL

2010AA BILLING PROVIDER NAME

NM1*85*2*LOCAL HOSPITAL*****XX*1122334455~

NM1 BILLING PROVIDER NAME INCLUDING NATIONAL PROVIDER ID

N3*3423 SMALL STREET~

N3 BILLING PROVIDER ADDRESS

N4*COLUMBUS*OH*432150000~

N4 BILLING PROVIDER LOCATION

REF*EI*111002222~

REF BILLING PROVIDER TAX IDENTIFICATION NUMBER

2000B SUBSCRIBER HL LOOP

HL*2*1*22*0~

HL SUBSCRIBER HIERARCHICAL LEVEL

SBR*P*18*34561W******CI~

SBR SUBSCRIBER INFORMATION

2010BA SUBSCRIBER NAME LOOP

NM1*IL*1*SMITH*JAMES*A***MI*34902390F~

NM1 SUBSCRIBER NAME

N3*934 NORTH STREET~

N3 SUBSCRIBER ADDRESS

N4*COLUMBUS*OH*432150000~

N4 SUBSCRIBER LOCATION

DMG*D8*19621015*M~

DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

2010BB PAYER NAME LOOP

NM1*PR*2*CONSERVATIVE INSURANCE*****PI*0012~

NM1 PAYER NAME

2300 CLAIM INFORMATION

CLM*W392-49141*14.84***13:A:1**A*Y*Y**********08~

CLM CLAIM LEVEL INFORMATION

CL1**1*01~

CL1 INSTITUTIONAL CLAIM CODE

REF*9A*459804390823~

REF REPRICED CLAIM NUMBER

REF*D9*32423466233~

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

HI*BK:53081~

HI HEALTH CARE DIAGNOSIS CODES

HCP*00*0**333001234*********T1~

HCP HEALTH CARE PRICING - OUT OF NETWORK INFORMATION

2310A ATTENDING PROVIDER NAME

NM1*71*1*RIVERS*DAWN****XX*2244224455~

NM1 ATTENDING PROVIDER

2400 SERVICE LINE

LX*1~

LX SERVICE LINE COUNTER

SV2*0301*HC:82270*14.84*UN*1~

SV2 INSTITUTIONAL SERVICE

TRAILER

SE*27*1024~

SE TRANSACTION SET TRAILER