Section title: X12 EDI Examples
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ASC X12 Version: 005010 | Transaction Set: 277 | TR3 ID: 005010X364

Example 1

In the following example, Your Insurance Company (Electronic Transmitter ID Number S00003) submitted an 837 Post Adjudicated Claims Data Reporting Professional file with an Originator Application Transaction Identifier of 206438976580901 in BHT03 directly to "All Payer Claim Database" (Electronic Transmitter ID Number APCD01) on February 20, 2019. All Payer Claim Database processed the file on February 21, 2019 and notified Your Insurance Company that although the file containing five claims for charges totaling $365.50 was accepted, there were two individual claims that were rejected and one received a warning. Following is the status information for the claims contained in the 837 transmission file:

The following claims were for provider Harry B Jones, MD (NPI 1546326897):
Female Patient's (Member ID Number 2222222222) claim for $100.00 for date of service February 14, 2019 was accepted. The payer claim control number is 220216359803X. The All Payer Claim Database assigned a data receiver claim control number of IC429783.

Male Patient's (Member ID Number 3333333333) claim for $65.00 was rejected for an invalid diagnosis code. The payer claim control number is 220216359954X. The All Payer Claim Database assigned a data receiver claim control number of IC847502.

Larry Jones' (Member ID Number 4444444444) claim for $100.00 for date of service February 11, 2019 was rejected because the place of service was missing or invalid. The payer claim control number is 220216359964X. The All Payer Claim Database assigned a data receiver claim control number of IC429805.

For provider John C. Smith, there is an additional location identifier of AB142 that is sent.

The following claims were for provider John C. Smith, MD (NPI 1546326780):
Mary Johnson's (Member ID Number 5555555555) claim for $50.50 for date of service February 10, 2019 was accepted but an exception occurred (STC03 = EZ). The warning given at the line level was for a procedure code not valid for the patient's age. The payer claim control number is 220216359806X. The All Payer Claim Database assigned a data receiver claim control number of IC429888.

Harriett Mills' (Member ID Number 6666666666) claim for $50.00 for date of service February 5, 2019 was accepted. The payer claim control number is 220216359807X. The All Payer Claim Database assigned a data receiver claim control number of IC429956.

X12 Syntax

ST*277*0003*005010X364~
BHT*0085*08*0000221*20190221*1025~
HL*1**20*1~
NM1*ACV*2*ALL PAYER CLAIMS DATABASE*****46*APCD01~
TRN*1*ABC12345~
DTP*050*D8*20190220~
DTP*009*D8*20190221~
HL*2*1*21*1~
NM1*40*2*YOUR INSURANCE COMPANY*****46*S00003~
TRN*2*206438976580901~
STC*DR02:20*20190221*WQ*365.5~
QTY*90*3~
QTY*AA*2~
AMT*YU*200.5~
AMT*YY*165~
HL*3*2*19*1~
NM1*85*1*JONES*HARRY*B**MD*XX*1546326897~
HL*4*3*PT~
NM1*QC*1*PATIENT*FEMALE****MI*2222222222~
TRN*2*PATIENT22222~
STC*DR02:20:PR*20190221*WQ*100~
REF*F8*IC847502~
REF*1K*220216359803X~
DTP*472*D8*20190214~
HL*5*3*PT~
NM1*QC*1*PATIENT*MALE****MI*3333333333~
TRN*2*PATIENT33333~
STC*DR06:21*20190221*U*65******DR06:255~
REF*F8*IC429783~
REF*1K*220216359954X~
DTP*472*D8*20190121~
HL*6*3*PT~
NM1*QC*1*JONES*LARRY****MI*4444444444~
TRN*2*JONES44444~
STC*DR03:26:77*20190221*U*100~
REF*F8*IC429805~
REF*1K*220216359964X~
DTP*472*D8*20190211~
HL*7*2*19*1~
NM1*85*1*SMITH*JOHN*C**MD*XX*1546326780~
TRN*1*0~
REF*LU*AB142~
QTY*QA*2~
AMT*YU*100.5~
HL*8*7*PT~
NM1*QC*1*JOHNSON*MARY****MI*5555555555~
TRN*2*JOHNSON55555~
STC*DR08:20:PR*20190221*EZ*50.5~
REF*F8*IC429888~
REF*1K*220216359806X~
DTP*472*D8*20190210~
SVC*HC:G9938*50.5*****1~
STC*DR08:475**EZ~
REF*6R*1~
DTP*472*D8*20190210~
HL*9*7*PT~
NM1*QC*1*MILLS*HARRIETT****MI*6666666666~
TRN*2*MILLS66666~
STC*DR02:20:PR*20190221*WQ*50~
REF*F8*IC429956~
REF*1K*220216359807X~
DTP*472*D8*20190205~
SE*63*0003~