Section title: X12 EDI Examples
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ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X298

Example 1: Adjudicated Claim submitted to All Payer Claim Data Base (APCD)

Assumptions

This is an example of an adjudicated claim by ABC Plan submitted to a Reporting Entity who is an APCD.

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*REPORTING ENTITY*****46*66783JJT~
HL*1**20*1~
PRV*BI*PXC*207Q00000X~
NM1*85*2*PHYSICIAN CLINIC*****XX*9876543210~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
REF*EI*587654321~
HL*2*1*22*1~
SBR*N~
NM1*IL*1*SMITH*JANE****MI*JS00111223333~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19430501*F~
NM1*ZD*2*DATA RECEIVER~
HL*3*2*23*0~
PAT*19~
NM1*QC*1*SMITH*TED****MI*JS00111224444~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19730501*M~
CLM*26463774*100***11:B:1~
REF*F8*20121092600001~
HI*ABK:M25375*ABF:M19072~
NM1*82*1*JONES*BARNABY****XX*1234567890~
NM1*77*2*PHYSICIAN CLINIC*****XX*9876543210~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
SBR*P*19*2222-SJ***6***CI~
AMT*D*75~
NM1*IL*1*SMITH*JANE****MI*JS00111223333~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
NM1*PR*2*ABC PLAN*****PI*59999~
DTP*573*D8*20120314~
REF*F8*20121092600001~
NM1*QC*1*SMITH*TED****MI*JS00111224444~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
LX*1~
SV1*HC:99213*100*UN*1*11**1**Y**Y*Y~
DTP*472*D8*20120204~
SVD*59999*75*HC:99213**1~
CAS*CO*45*25~
DTP*573*D8*20120314~
SE*49*0021~