ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X222
Example 02: Encounter
Patient is the same person as the Subscriber. Payer is an HMO. Encounter is transmitted through a clearinghouse. Submitter is the billing provider, receiver is a payer.
SUBSCRIBER/PATIENT: Ted Smith
PATIENT ADDRESS: 236 N. Main St., Miami, Fl, 33413,
TELEPHONE NUMBER: 305-555-1111
SEX: M
DOB: 05/01/43
EMPLOYER: ACME Inc.
GROUP #: 12312-A
PAYER ID NUMBER: SSN
SSN: 000-22-1111
DESTINATION PAYER: Alliance Health and Life Insurance Company (AHLIC),
PAYER ADDRESS: 2345 West Grand Blvd, Detroit, MI 48202. ,
AHLIC #: 741234
SUBMITTER: Premier Billing Service
EDI#: TGJ23
CONTACT PERSON AND PHONE NUMBER: JERRY, 305-555-2222 ext. 231
RECEIVER: Alliance Health and Life Insurance Company (AHLIC),
EDI #: 66783JJT
BILLING PROVIDER: Dr. Ben Kildare,
ADDRESS: 234 Seaway St, Miami, FL, 33111
NPI: 9876543210
TIN: 587654321
Taxonomy Code: 203BF0100Y
PAY-TO PROVIDER: Kildare Associates,
PROVIDER ADDRESS: 2345 Ocean Blvd, Miami, Fl 33111
RENDERING PROVIDER: Dr. Ben Kildare/Family Practitioner
PATIENT ACCOUNT NUMBER: 2-646-2967
CASE: Patient has sore throat.
INITIAL VISIT: DOS=10/03/06. POS=Office
SERVICES: Office visit, intermediate service, established patient, throat culture.
CHARGES: Office first visit = $40.00, Lab test for strep = $15.00
FOLLOW-UP VISIT: DOS=10/10/06 POS=Office
Antibiotics didn’t work (pain continues).
SERVICES: Office visit, intermediate service, established patient, mono screening.
CHARGES: Follow-up visit = $35.00, lab test for mono = $10.00.
TOTAL CHARGES: $100.00.
ELECTRONIC ROUTE: Billing provider (sender) to Clearinghouse to Alliance Health and Life Insurance Company (AHLIC);
Clearinghouse claim identification number = 17312345600006351.
Transmission Explanation
HEADER
ST*837*0021*005010X222~
ST TRANSACTION SET HEADER
BHT*0019*00*0123*20061015*1023*RP~
BHT BEGINNING OF HIERARCHICAL TRANSACTION
1000A SUBMITTER
NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~
NM1 SUBMITTER NAME
PER*IC*JERRY*TE*3055552222*EX*231~
PER SUBMITTER EDI CONTACT INFORMATION
1000B RECEIVER
NM1*40*2*AHLIC*****46*66783JJT~
NM1 RECEIVER NAME
2000A BILLING PROVIDER HL LOOP
HL*1**20*1~
HL - BILLING PROVIDER
PRV*BI*PXC*203BF0100Y~
PRV BILLING PROVIDER SPECIALTY INFORMATION
2010AA BILLING PROVIDER
NM1*85*2*BEN KILDARE SERVICE*****XX*9876543210~
NM1 BILLING PROVIDER NAME
N3*234 SEAWAY ST~
N3 BILLING PROVIDER ADDRESS
N4*MIAMI*FL*33111~
N4 BILLING PROVIDER LOCATION
REF*EI*587654321~
REF - BILLING PROVIDER TAX IDENTIFICATION
2010AB PAY-TO PROVIDER
NM1*87*2~
NM1 PAY-TO PROVIDER NAME
N3*2345 OCEAN BLVD~
N3 PAY-TO PROVIDER ADDRESS
N4*MIAMI*FL*33111~
N4 PAY-TO PROVIDER CITY
2000B SUBSCRIBER HL LOOP
HL*2*1*22*0~
HL - SUBSCRIBER
SBR*P*18*12312-A******HM~
SBR SUBSCRIBER INFORMATION
2010BA SUBSCRIBER
NM1*IL*1*SMITH*TED****MI*000221111~
NM1 SUBSCRIBER NAME
N3*236 N MAIN ST~
N3 SUBSCRIBER ADDRESS
N4*MIAMI*FL*33413~
N4 SUBSCRIBER CITY
DMG*D8*19430501*M~
DMG SUBSCRIBER DEMOGRAPHIC INFORMATION
2010BB SUBSCRIBER/PAYER
NM1*PR*2*ALLIANCE HEALTH AND LIFE INSURANCE*****PI*741234~
NM1 PAYER NAME
2300 CLAIM
CLM*26462967*100***11:B:1*Y*A*Y*I~
CLM CLAIM LEVEL INFORMATION
DTP*431*D8*19981003~
DTP DATE OF ONSET
REF*D9*17312345600006351~
REF CLEARING HOUSE CLAIM NUMBER (Added by CH)
HI*BK:0340*BF:V7389~
HI HEALTH CARE DIAGNOSIS CODES
2310C SERVICE LOCATION
NM1*77*2*KILDARE ASSOCIATES*****XX*5812345679~
NM1 SERVICE FACILITY LOCATION
N3*2345 OCEAN BLVD~
N3 SERVICE FACILITY ADDRESS
N4*MIAMI*FL*33111~
N4 SERVICE FACILITY CITY/STATE/ZIP
2400 SERVICE LINE
LX*1~
LX SERVICE LINE COUNTER
SV1*HC:99213*40*UN*1***1~
SV1 PROFESSIONAL SERVICE
DTP*472*D8*20061003~
DTP DATE - SERVICE DATE(S)
2400 SERVICE LINE
LX*2~
LX SERVICE LINE COUNTER
SV1*HC:87072*15*UN*1***1~
SV1 PROFESSIONAL SERVICE
DTP*472*D8*20061003~
DTP DATE - SERVICE DATE(S)
2400 SERVICE LINE
LX*3~
LX SERVICE LINE COUNTER
SV1*HC:99214*35*UN*1***2~
SV1 PROFESSIONAL SERVICE
DTP*472*D8*20061010~
DTP DATE - SERVICE DATE(S)
2400 SERVICE LINE
LX*4~
LX SERVICE LINE COUNTER
SV1*HC:86663*10*UN*1***2~
SV1 PROFESSIONAL SERVICE
DTP*472*D8*20061010~
DTP DATE - SERVICE DATE(S)
TRAILER
SE*41*0021~
SE TRANSACTION SET TRAILER