Section title: X12 EDI Examples
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ASC X12 Version: 006020 | Transaction Set: 832 | TR3 ID: 006020X304

Example 1: Price Sheet

Statewide Health Plan has contracted with Center City Health Clinic to be part of the "Statewide PPO" network, assigned an identifier of "SWPPO1" by the Statewide Health Plan. Rates for the contract year starting January 1, 2012 and ending on December 31, 2012 have been established for the related specific services at fixed prices, independent of the provider's charge. These rates apply to all physicians and other providers working for the clinic at all related locations. For services not on the fee schedule, Center City Health Clinic has agreed to a 33% discount from their normal billed amount. This fee schedule information is being conveyed using an 832 transaction from Statewide Health Plan to Center City Health Clinic as an initial notification of the fee schedule details.

Transmission Explanation

Table 1

ST*832*0001*006020X304~

This is an 832 transaction with a control number within the Functional Group of "0001" and is based upon implementation "006020X304".

BCT*PS*SHP-PPO-2012********00~

Code PS indicates that this is a price sheet. The reference for the fee schedule is "SHP-PPO-2012". The BCT10 value of "00" indicates that this is an original fee schedule.

CTP*PF*****DIS*.67~

The fee schedule relates to charges submitted on a professional claim. The allowed amount for services not itemized in table 2 is 67% of the submitted charge.

REF*CE*SWPPO1~

The class of contract is "SWPPO1", identifying the Statewide PPO network contract.

DTM*007*20120101~

The effective date of this fee schedule is January 1, 2012.

DTM*396*20121231~

The termination date of this fee schedule is December 31, 2012.

N1*PR*STATEWIDE HEALTH PLAN~

The health plan's name is "Statewide Health Plan."

N3*3333 OCEAN STREET~

The health plan's street address is "3333 Ocean Street".

N4*SOUTH MIAMI*FL*33000~

The health plan's city is "South Miami", in "Florida" with a ZIP Code of "33000".

REF*2U*435261708~

Statewide's ID is "435261708".

PER*IC**TE*8005551212~

Statewide's Provider telephone number related to fee schedule questions is "800-555-1212".

N1*1P*CENTER CITY HEALTH CLINIC*XX*12345678980~

The contracted provider receiving this fee schedule is "Center City Health Clinic, with a National Provider Identifier of "1234567890".

N3*123 MAIN STREET~

Center City Health Clinic is located at "123 Main Street".

N4*FORT LAUDERDALE*FL*32945~

Center City Health Clinic is located in "Fort Lauderdale", "Florida", with a ZIP Code of "32945".

Table 2

LIN*1*HC*99201~

The first fee is for HCPCS code "99201" (Limited Office Visit).

CTP**DSC*26.45~

The fee payable per unit of service for a Limited Office Visit is $26.45.

LIN*2*HC*99202~

The second fee is for HCPCS code "99202" (Intermediate Office Visit).

CTP**DSC*37.75~

The fee payable per unit of service for an Intermediate Office Visit is $37.75.

LIN*3*HC*99203~

The third fee is for HCPCS code "99203" (Extended Office Visit).

CTP**DSC*53~

The fee payable per unit of service for an Extended Office Visit is $53.

LIN*4*HC*99204~

The fourth fee is for HCPCS code "99204" (Comprehensive Office Visit).

CTP**DSC*72.15~

The fee payable per unit of service for a Comprehensive Office Visit is $72.15.

LIN*5*HC*90716~

The fifth fee is for HCPCS code "90716" (Varicella Immunization).

CTP**DSC*12~

The fee payable per unit of service for a Varicella Immunization is $12.

LIN*6*HC*90632~

The sixth fee is for HCPCS code "90632" (Hepititis A Adult Immunization).

MEA**AV**YR*18~

The minimum age for this fee with this service is 18 years.

CTP**DSC*15~

The fee payable per unit of service for a Hepititis A Adult Immunization is $15.

LIN*7*HC*90633~

The seventh fee is for HCPCS code "90633" (Hepititis A Child Immunization).

MEA**AV**YR*17~

The maximum age for this fee with this service is 17 years.

CTP**DSC*13~

The fee payable per unit of service for a Hepititis A Child Immunization is $13.

Table 3

CTT*7~

There are seven rows to this fee schedule.

SE*32*0001~

Transaction set "0001" contains 32 segments and is ended.