ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X224
Example 01: Commercial Health Insurance
The patient is a different person than the subscriber. The payer is a commercial health insurance company.
SUBSCRIBER: Jane Smith
KEY INSURANCE COMPANY ID #: SSN
SSN: 111-22-3333
PATIENT: Ted Smith
PATIENT ADDRESS: 236 N. Main St., Miami, Fl, 33413
SEX: M
DOB: 05/01/1992
PATIENT RELATIONSHIP: Child
DESTINATION PAYER: Insurance Company XYZ
RECEIVER: Insurance Company XYZ
ETIN#: 66783JJT
SUBMITTER: Premier Billing Service
ETIN#: TGJ23
BILLING PROVIDER: Dental Associates
NPI: 1234567890
TIN: 587654321
ADDRESS: 234 Seaway St., Miami, FL, 33111
RENDERING PROVIDER: Dr. Ben Kildare
NPI: 9876543210
PATIENT ACCOUNT NUMBER: 2-640-3774
DOS: 20061029
POS=Office
SERVICES RENDERED: Two surface amalgam on tooth #12 (mesial and occlusal surfaces) and prophy.
CHARGES: amalgam = $100.00, prophy = $50.00.
ELECTRONIC ROUTE: VAN submits claim on behalf of billing provider (submitter) to Insurance Company XYZ (receiver).
VAN CLAIM IDENTIFICATION NUMBER: 17312345600006351.
Transmission Explanation
HEADER
ST*837*3456*005010X224~
ST TRANSACTION SET HEADER
BHT*0019*00*0123*20061123*1023*CH~
BHT TRANSACTION SET HIERARCHY AND CONTROL INFORMATION
1000A SUBMITTER
NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~
NM1 SUBMITTER
PER*IC*JERRY*TE*7176149999~
PER SUBMITTER EDI CONTACT INFORMATION
1000B RECEIVER
NM1*40*2*INSURANCE COMPANY XYZ*****46*66783JJT~
NM1 RECEIVER
2000A BILLING PROVIDER HL LOOP
HL*1**20*1~
HIERARCHAL LEVEL 1
2010AA BILLING PROVIDER
NM1*85*2*DENTAL ASSOCIATES*****XX*1234567890~
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'S TAX IDENTIFICATION
2000B SUBSCRIBER HL LOOP
HL*2*1*22*1~
HIERARCHAL LEVEL 2
SBR*P********CI~
SBR SUBSCRIBER INFORMATION
2010BA SUBSCRIBER
NM1*IL*1*SMITH*JANE****MI*111223333~
NM1 SUBSCRIBER'S NAME
2010BB SUBSCRIBER/PAYER
NM1*PR*2*INSURANCE COMPANY XYZ*****PI*66783JJT~
NM1 PAYER'S NAME
2000C PATIENT'S HL LOOP
HL*3*2*23*0~
HIERARCHAL LEVEL 3
PAT*19~
PAT PATIENT INFORMATION
2010CA PATIENT
NM1*QC*1*SMITH*TED~
NM1 PATIENT'S NAME
N3*236 N MAIN ST~
N3 PATIENT'S ADDRESS
N4*MIAMI*FL*33413~
N4 PATIENT'S CITY
DMG*D8*19920501*M~
DMG PATIENT DEMOGRAPHIC INFORMATION
2300 CLAIM
CLM*26403774*150***11:B:1*Y*A*Y*I~
CLM HEALTH CLAIM INFORMATION
DTP*472*D8*20061029~
DTP DATE - SERVICE DATE
REF*D9*17312345600006351~
REF VAN CLAIM NUMBER
2310B RENDERING PROVIDER
NM1*82*1*KILDARE*BEN****XX*9876543210~
NM1 RENDERING PROVIDER’S NAME
PRV*PE*PXC*1223G0001X~
PRV RENDERING PROVIDER INFORMATION
2400 SERVICE LINE
LX*1~
LX SERVICE LINE NUMBER
SV3*AD:D2150*100****1~
SV3 DENTAL SERVICE
TOO*JP*12*M:O~
TOO TOOTH NUMBER/SURFACES
2400 SERVICE LINE
LX*2~
LX SERVICE LINE NUMBER
SV3*AD:D1110*50****1~
SV3 DENTAL SERVICE
TRAILER
SE*31*3456~
SE TRANSACTION SET TRAILER