ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X222
Example 12: Out of Network Repriced Claim
An out of network claim is being transmitted from a Regional PPO (Preferred Provider Organization) to a commercial health insurance company. The patient is a child of the subscriber. In this situation, the provider has sent the claim to a clearinghouse, which then forwarded the claim to the repricer; the claim has been determined to be out of network and is now being forwarded to the appropriate payer for payment.
SUBSCRIBER: Matthew R. Smith
ADDRESS: 5698 South Street, Billings, MO 919910000
SEX: M
DATE OF BIRTH: 10/15/195
EMPLOYER: Lumber Company.
GROUP NUMBER: 232AA
MEMBER ID: 57976235C
PATIENT: Tom E. Smith
ADDRESS: 5698 South Street, Billings, MO 919910000
SEX: M
DATE OF BIRTH: 08/07/1996
PATIENT ACCOUNT NUMBER: TS234H3
OTHER INSURANCE: Secondary Insurance Company
PAYER ID: 95645
GROUP NUMBER: 56567
OTHER INSURED MEMBER ID: 23424570
SUBMITTER: Regional PPO Network
SUBMITTER ID: 123456789
RECEIVER: Conservative Insurance
RECEIVER ID: 000110002
DESTINATION PAYER: Conservative Insurance
PAYER ID NUMBER: 00123
BILLING PROVIDER: Emergency Physicians Group
ADDRESS: 7423 Super Street, Billings, MO 919910000
NATIONAL PROVIDER ID (NPI): 1122334455
TAX IDENTIFICATION NUMBER (TIN): 111-00-2222
RENDERING PROVIDER: Jackie D. Blue
NATIONAL PROVIDER ID (NPI): 1112223336
REPRICING INFORMATION:
TOTAL CHARGES: $252.71
TOTAL REPRICED AMOUNT: $0
SAVINGS AMOUNT: $0
TIN FOR THE REPRICING ORGANIZATION: 333001234
DATE OF SERVICE: 05/06/05
Transmission Explanation
HEADER
ST*837*1024*005010X222~
ST TRANSACTION SET HEADER
BHT*0019*00*1024*20050711*1335*CH~
BHT BEGINNING OF HIERARCHICAL TRANSACTION
1000A SUBMITTER NAME
NM1*41*2*REGIONAL PPO NETWORK*****46*123456789~
NM1 SUBMITTER NAME
PER*IC*SUBMITTER CONTACT INFO*TE*8001231234~
PER SUBMITTER EDI CONTACT INFORMATION
1000B RECEIVER NAME
NM1*40*2*CONSERVATIVE INSURANCE*****46*000110002~
NM1 RECEIVER NAME
2000A BILLING PROVIDER
HL*1**20*1~
HL BILLING PROVIDER HIERARCHICAL LEVEL
2010AA BILLING PROVIDER NAME
NM1*85*2*EMERGENCY PHYSICIANS GROUP*****XX*1122334455~
NM1 BILLING PROVIDER NAME INCLUDING NATIONAL PROVIDER ID
N3*7423 SUPER STREET~
N3 BILLING PROVIDER ADDRESS
N4*BILLINGS*MO*919910000~
N4 BILLING PROVIDER LOCATION
REF*EI*111002222~
REF BILLING PROVIDER TAX IDENTIFICATION NUMBER
2000B SUBSCRIBER HL LOOP
HL*2*1*22*1~
HL SUBSCRIBER HIERARCHICAL LEVEL
SBR*P**232AA******CI~
SBR SUBSCRIBER INFORMATION
2010BA SUBSCRIBER NAME LOOP
NM1*IL*1*SMITH*MATTHEW*R***MI*57976235C~
NM1 SUBSCRIBER NAME
N3*5698 SOUTH STREET~
N3 SUBSCRIBER ADDRESS
N4*BILLINGS*MO*919910000~
N4 SUBSCRIBER LOCATION
DMG*D8*19561015*M~
DMG SUBSCRIBER DEMOGRAPHIC INFORMATION
2010BB PAYER NAME LOOP
NM1*PR*2*CONSERVATIVE INSURANCE*****PI*00123~
NM1 PAYER NAME
2000C - PATIENT HL LOOP
HL*3*2*23*0~
HL PATIENT HIERARCHICAL LEVEL
PAT*19~
PAT PATIENT INFORMATION
2010CA PATIENT NAME
NM1*QC*1*SMITH*TOM*E~
NM1 PATIENT NAME
N3*5698 SOUTH STREET~
N3 PATIENT STREET ADDRESS
N4*BILLINGS*MO*919910000~
N4 PATIENT LOCATION
DMG*D8*19960807*M~
DMG PATIENT DEMOGRAPHIC INFORMATION
2300 CLAIM INFORMATION
CLM*TS234H3*252.71***23:B:1*Y*A*Y*Y*P~
CLM CLAIM LEVEL INFORMATION
REF*9A*0902345406~
REF REPRICED CLAIM NUMBER
REF*D9*687534234346~
REF CLEARING HOUSE CLAIM NUMBER (ASSIGNED BY THE CLEARING HOUSE WHEN TRANSMITTING TO THE REPRICER)
HI*BK:9951~
HI HEALTH CARE DIAGNOSIS CODES
HCP*00*0**333001234*********T1~
HCP HEALTH CARE PRICING - OUT OF NETWORK INFORMATION
2310B RENDERING PROVIDER
NM1*82*1*BLUE*JACKIE*D***XX*1112223336~
NM1 RENDERING PROVIDER
2320 OTHER SUBSCRIBER INFORMATION
SBR*S*18*56567******CI~
SBR OTHER SUBSCRIBER INFORMATION
OI***Y***Y~
OI OTHER INSURANCE COVERAGE INFORMATION
2330A OTHER SUBSCRIBER NAME
NM1*IL*1*SMITH*TOM*E***MI*23424570~
NM1 OTHER SUBSCRIBER NAME
N3*5698 SOUTH STREET~
N3 OTHER SUBSCRIBER ADDRESS
N4*BILLINGS*MO*919910000~
N4 OTHER SUBSCRIBER LOCATION
2330B OTHER PAYER NAME
NM1*PR*2*SECONDARY INSURANCE COMPANY*****PI*95645~
NM1 OTHER PAYER NAME
2400 SERVICE LINE
LX*1~
LX SERVICE LINE COUNTER
SV1*HC:99284*252.71*UN*1***1~
SV1 PROFESSIONAL SERVICE
DTP*472*D8*20050506~
DTP DATE - SERVICE DATES
TRAILER
SE*39*1024~
SE TRANSACTION SET TRAILER