Example 3a: Claim from Billing Provider to Payer A

Transmission Explanation

HEADER

ST*837*0021*005010X222~

ST TRANSACTION SET HEADER

BHT*0019*00*0123*20051015*1023*CH~

BHT BEGINNING OF HIERARCHICAL TRANSACTION

1000A SUBMITTER

NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~

NM1 SUBMITTER NAME

PER*IC*JERRY*TE*3055552222~

PER SUBMITTER EDI CONTACT INFORMATION

1000B RECEIVER

NM1*40*2*XYZ REPRICER*****46*66783JJT~

NM1 RECEIVER NAME

2000A BILLING PROVIDER HL LOOP

HL*1**20*1~

HL - BILLING PROVIDER

2010AA BILLING PROVIDER

NM1*85*1*KILDARE*BEN****XX*1999996666~

NM1 BILLING PROVIDER NAME

N3*234 SEAWAY ST~

N3 BILLING PROVIDER ADDRESS

N4*MIAMI*FL*33111~

N4 BILLING PROVIDER CITY/STATE/ZIP

REF*EI*123456789~

REF - BILLING PROVIDER TAX IDENTIFICATION

PER*IC*CONNIE*TE*3055551234~

PER BILLING PROVIDER CONTACT INFORMATION

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/STATE/ZIP

2000B SUBSCRIBER HL LOOP

HL*2*1*22*1~

HL - SUBSCRIBER

SBR*P********CI~

SBR SUBSCRIBER INFORMATION

2010BA SUBSCRIBER

NM1*IL*1*SMITH*JANE****MI*111223333~

NM1 SUBSCRIBER NAME

DMG*D8*19430501*F~

DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

2010BB PAYER

NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~

NM1 PAYER NAME

N3*3333 OCEAN ST~

N3 PAYER ADDRESS

N4*SOUTH MIAMI*FL*33000~

N4 PAYER CITY/STATE/ZIP

REF*G2*PBS3334~

REF BILLING PROVIDER SECONDARY IDENTIFICATION

2000C PATIENT HL LOOP

HL*3*2*23*0~

HL - PATIENT

PAT*19~

PAT PATIENT INFORMATION

2010CA PATIENT

NM1*QC*1*SMITH*TED~

NM1 PATIENT NAME

N3*236 N MAIN ST~

N3 PATIENT ADDRESS

N4*MIAMI*FL*33413~

N4 PATIENT CITY/STATE/ZIP

DMG*D8*19730501*M~

DMG PATIENT DEMOGRAPHIC INFORMATION

2300 CLAIM

CLM*26407789*79.04***11:B:1*Y*A*Y*I*P~

CLM CLAIM LEVEL INFORMATION

HI*BK:4779*BF:2724*BF:2780*BF:53081~

HI HEALTH CARE DIAGNOSIS CODES

2310B RENDERING PROVIDER

NM1*82*1*KILDARE*BEN****XX*1999996666~

NM1 RENDERING PROVIDER NAME

PRV*PE*PXC*204C00000X~

PRV RENDERING PROVIDER INFORMATION

REF*G2*KA6663~

REF RENDERING PROVIDER SECONDARY IDENTIFICATION

2310C SERVICE FACILITY LOCATION

NM1*77*2*KILDARE ASSOCIATES*****XX*1581234567~

NM1 SERVICE FACILITY LOCATION

N3*2345 OCEAN BLVD~

N3 SERVICE FACILITY ADDRESS

N4*MIAMI*FL*33111~

N4 SERVICE FACILITY CITY/STATE/ZIP

2320 OTHER SUBSCRIBER INFORMATION

SBR*S*01*******CI~

SBR OTHER SUBSCRIBER INFORMATION

OI***Y*P**Y~

OI OTHER INSURANCE COVERAGE INFORMATION

2330A OTHER SUBSCRIBER NAME

NM1*IL*1*SMITH*JACK****MI*T55TY666~

NM1 OTHER SUBSCRIBER NAME

N3*236 N MAIN ST~

N3 OTHER SUBSCRIBER ADDRESS

N4*MIAMI*FL*33111~

N4 OTHER SUBSCRIBER CITY/STATE/ZIP

2330B OTHER SUBSCRIBER/PAYER

NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~

NM1 OTHER PAYER NAME

2400 SERVICE LINE

LX*1~

LX SERVICE LINE COUNTER

SV1*HC:99213*43*UN*1***1:2:3:4~

SV1 PROFESSIONAL SERVICE

DTP*472*D8*20051003~

DTP DATE - SERVICE DATE(S)

2400 SERVICE LINE

LX*2~

LX SERVICE LINE COUNTER

SV1*HC:90782*15*UN*1***1:2~

SV1 PROFESSIONAL SERVICE

DTP*472*D8*20051003~

DTP DATE - SERVICE DATE(S)

2400 SERVICE LINE

LX*3~

LX SERVICE LINE COUNTER

SV1*HC:J3301*21.04*UN*1***1:2~

SV1 PROFESSIONAL SERVICE

DTP*472*D8*20051003~

DTP DATE - SERVICE DATE(S)

TRAILER

SE*52*0021~

SE TRANSACTION SET TRAILER

Payer A returned an electronic remittance advice (835) to the Billing Provider with the following amounts and Claim Adjustment Reason Codes:

SUBMITTED CHARGES (CLP03): 79.04

AMOUNT PAID (CLP04): 39.15

PATIENT RESPONSIBILITY (CLP05): 36.89

The CAS at the Claim level was:

CAS*PR*1*21.89**2*15~ (INDICATES A $15.00 CO-INSURANCE PAYMENT AND $21.89 DEDUCTIBLE PAYMENT IS DUE FROM PATIENT).

In addition, Payer A adjusted the office visit charges to $40.00 by Contractual Agreement.

The CAS on line 1 was: CAS*CO*42*3~. Because the other lines did not have adjustments, there are no CAS segments for those lines.

See the Introduction for a discussion on cross walking 835s to 837s.