X12 Version: 008060 | Transaction Set: 837 | TR3 ID: 008060X324
Example: Inpatient Hospital Stay
BUSINESS SCENARIO:
Patient is an adult male admitted for an inpatient hospital stay that includes a Device Identifier (DI) for an implantable device. Subscriber is the Patient. The Payer is Commercial.
Example:
SUBMITTER:
SUBMITTER NAME: PROVIDER MEDICAL GROUP
SUBMITTER ID: N305
SUBMITTER CONTACT NAME: NINA
SUBMITTER CONTACT NUMBER: 6155551212 ext. 911
RECEIVER:
RECEIVER NAME: COMMERCIAL RECEIVER
RECEIVER ID: 05440
BILLING PROVIDER:
BILLING PROVIDER TAXONOMY: 203BA0200N
BILLING PROVIDER NAME: PROVIDER MEDICAL GROUP
BILLING PROVIDER NPI: 2366554859
BILLING PROVIDER ADDRESS: 123 MAIN STREET, KANSAS CITY, MO, 64105-1909
BILLING PROVIDER TIN: 756473826
SUBSCRIBER:
SUBSCRIBER NAME: JOHN JONES
SUBSCRIBER ID: 111222345ACI
SUBSCRIBER ADDRESS: 123 RAINBOW ROAD, KANSAS CITY, MO, 64105
SUBSCRIBER DOB: 03/03/1954
SUBSCRIBER SEX: M
DESTINATION PAYER:
PAYER NAME: COMMERCIAL
PAYER SECONDARY IDENTIFICATION: 05440
PATIENT:
Same as Primary Subscriber
CLAIM INFORMATION:
ORIGINAL CLAIM CREATION DATE: 01/12/2025
PROVIDER ASSIGNED CLAIM IDENTIFIER: 153829140764352987432
TOTAL CHARGES: $3900
PLACE OF SERVICE CODE: 11
CLAIM FREQUENCY CODE: 1
TIME OF DISCHARGE: 4:00PM
STATEMENT PERIOD DATE: 01/12/2025 – 01/22/2025
DATE OF ADMISSION: 01/12/2025
ADMISSION TYPE CODE: 3 (elective)
PATIENT STATUS: 01 (discharged to home)
DEVICE IDENTIFIER: 00880304454934
PRINCIPAL DIAGNOSIS CODE: M16.11
ADMITTING DIAGNOSIS CODE: M16.11
OCCURRENCE CODE AND DATE: 42, 01/12/2025 (Date of Discharge)
VALUE CODE AND AMOUNT: 80, 10 (number of covered days)
ATTENDING PROVIDER:
ATTENDING PROVIDER NAME: JACOB E. TOWNSEND
ATTENDING PROVIDER NPI: 5678912345
SERVICE LINE NUMBER:
SERVICE LINE 1
REVENUE CODE: 0120
LINE ITEM CHARGE AMOUNT: $200
UNIT OR BASIS FOR MEASURMENT CODE: DA
SERVICE UNIT COUNT: 9
SERVICE LINE 2
REVENUE CODE: 0360
LINE ITEM CHARGE AMOUNT: $1700
UNIT OR BASIS FOR MEASURMENT CODE: UN
SERVICE UNIT COUNT: 1
SERVICE LINE 3
REVENUE CODE: 0370
LINE ITEM CHARGE AMOUNT: $400
UNIT OR BASIS FOR MEASURMENT CODE: UN
SERVICE UNIT COUNT: 1
Transmission Explanation
HEADER
ST*837*0001*008060X324~
ST TRANSACTION SET HEADER
BHT*0019*00*12345*20250112*1549*CH~
BHT BEGINNING OF HIERARCHICAL TRANSACTION
1000A SUBMITTER NAME
NM1*41*2*PROVIDER MEDICAL GROUP*****46*N305~
NM1 SUBMITTER NAME
PER*IC*NINA*TE*6155551212*EX*911~
PER SUBMITTER EDI CONTACT INFORMATION
1000B RECEIVER NAME
NM1*40*2*COMMERCIAL RECEIVER*****46*05440~
NM1 RECEIVER NAME
2000A BILLING PROVIDER
HL*1**20*1~
HL BILLING PROVIDER HIERARCHICAL LEVEL
PRV*BI*PXC*203BA0200N~
PRV BILLING PROVIDER SPECIALTY INFORMATION
2010AA BILLING PROVIDER NAME
NM1*85*2*PROVIDER MEDICAL GROUP*****XX*2366554859~
NM1 BILLING PROVIDER NAME
N3*123 Main Street~
N3 BILLING PROVIDER ADDRESS
N4*KANSAS CITY*MO*641051909~
N4 BILLING PROVIDER LOCATION
REF*EI*756473826~
REF BILLING PROVIDER TAX IDENTIFICATION
2000B SUBSCRIBER HL LOOP
HL*2*1*22*0~
HL SUBSCRIBER HIERARCHICAL LEVEL
SBR*P*18*******CI~
SBR SUBSCRIBER INFORMATION
2010BA SUBSCRIBER NAME LOOP
NM1*IL*1*JONES*JOHN****MI*111222345ACI~
NM1 SUBSCRIBER NAME
N3*123 RAINBOW ROAD~
N3 SUBSCRIBER ADDRESS
N4*KANSAS CITY*MO*64105~
N4 SUBSCRIBER CITY, STATE, ZIP
DMG*D8*19540303~
DMG SUBSCRIBER DEMOGRAPHIC INFORMATION
DMH*M*248152002~
DMH SUBSCRIBER EXTENDED DEMOGRAPHIC INFORMATION
2010BB PAYER NAME LOOP
NM1*PR*2*COMMERCIAL~
NM1 PAYER NAME
REF*2U*05440~
REF PAYER SECONDARY IDENTIFICATION
2300 CLAIM INFORMATION
CLM*153829140764352987432*3900***11:A:1*Y*A*Y*Y~
CLM CLAIM LEVEL INFORMATION
DTP*523*D8*20250112~
DTP ORIGINAL CLAIM CREATION DATE
DTP*096*TM*0400~
DTP DISCHARGE TIME
DTP*435*DT*20250112~
DTP ADMISSION DATE/HOUR OR START OF CARE DATE
DTP*434*RD8*20250112–20250122~
DTP STATEMENT DATES
CL1*3**01~
CL1 INSTITUTIONAL CLAIM CODE
CR8*Z*1****00880304454934~
CR8 HIGH RISK IMPLANTED OR EXPLANTED DEVICE
HI*ABK:M1611~
HI PRINCIPAL DIAGNOSIS
HI*ABJ:M1611~
HI ADMITTING DIAGNOSIS
HI*BH:42:20250112~
HI OCCURRENCE INFORMATION
HI*BE:80:::10~
HI VALUE INFORMATION
2310A ATTENDING PROVIDER NAME LOOP
NM1*71*1*TOWNSEND*JACOB*E***XX*5678912345~
NM1 ATTENDING PROVIDER NAME
2400 SERVICE LINE NUMBER
LX*1~
LX SERVICE LINE NUMBER
SV2*0120**200*DA*9~
SV2 INSTITUTIONAL SERVICE LINE
LX*2~
LX SERVICE LINE NUMBER
SV2*360**1700*UN*1~
SV2 INSTITUTIONAL SERVICE LINE
LX*3~
LX SERVICE LINE NUMBER
SV2*370**400*UN*1~
SV2 INSTITUTIONAL SERVICE LINE
SE*39*0001~
SE TRANSACTION SET TRAILER