ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X298
Example 02: Claim adjudicated by secondary payer
Assumptions
This is an example of a claim adjudicated by the primary payer, XYZ Plan (payer ID 78888), and subsequently adjudicated by the secondary payer, ABC Plan (payer ID 59999). ABC Plan is now submitting the claim as a Medicaid Encounter to Medicaid Agency. This claim is for Ted Smith. Ted is on the policy of Jane Smith at XYZ Plan.
Transmission
ST*837*0021*005010X298~
BHT*0019*00*244579*20120315*1023*RP~
NM1*41*2*ABC PLAN*****46*TGJ23~
PER*IC*IT GROUP*TE*3055552222*EX*231~
NM1*40*2*MEDICAID AGENCY*****46*66783JJT~
HL*1**20*1~
PRV*BI*PXC*208D00000X~
NM1*85*2*PHYSICIAN CLINIC*****XX*9876543210~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
REF*EI*587664321~
HL*2*1*22*0~
SBR*N*18~
NM1*IL*1* SMITH*TED****MI*JS00111224444~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19730501*M~
NM1*ZD*2*MEDICAID AGENCY~
CLM*26463774*100***11:B:1~
HI*BK:0340*BF:V7389~
NM1*82*1*JONES*JOHN****XX*1234567890~
NM1*77*2*PHYSICIAN CLINIC~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
SBR*P*01*559876***1***CI~
AMT*D*60~
NM1*IL*1*SMITH*JANE****MI*987644332~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
NM1*PR*2*XYZ PLAN*****PI*78888~
DTP*573*D8*20120107~
REF*F8*32141092600001~
NM1*QC*1*SMITH*TED****MI*7754321~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
SBR*S*01*2222-SJ***6***CI~
AMT*D*15~
NM1*IL*1* SMITH*TED****MI*JS00111224444~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
NM1*PR*2*ABC PLAN*****PI*59999~
DTP*573*D8*20120214~
REF*F8*4463589321~
LX*1~
SV1*HC:99213*100*UN*1***1**Y~
DTP*472*D8*20120204~
SVD*78888*60*HC:99213**1~
CAS*CO*45*25~
CAS*PR*1*15~
DTP*573*D8*20120107~
SVD*59999*15*HC:99213**1~
CAS*OA*23*85~
DTP*573*D8*20120214~
SE*54*0021~