ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X292
Example 02: Two Claims for the Same Provider
This example combines two claims for the same provider.
DESTINATION PAYER: TRICARE
PAYER ID: 99999
BILLING PROVIDER: Jones Hospital
BILLING PROVIDER ADDRESS: 225 MAIN STREET, ANYWHERE, PA, 17111-1234
BILLING PROVIDER SPECIALTY: 282N00000X
BILLING PROVIDER EMPLOYER ID: 123456789
BILLING PROVIDER NPI: 1234567890
SUBMITTER ETIN: 12345
SUBMITTER CONTACT: Jane Doe
SUBMITTER CONTACT TELEPHONE: (111)222-3333
CLAIM #1:
SUBSCRIBER: John T. Doe
MEMBER ID: 030005074
SUBSCRIBER ADDRESS: 125 City Avenue, Anywhere, PA, 17111
DOB: November 11, 1968
SEX: M
PATIENT ACCOUNT #: 756048Q
CLAIM AMOUNT: 89.95
TYPE OF BILL: 131
PRINCIPAL DIAGNOSIS: 366.9
OTHER DIAGNOSIS: 401.9, 794.31
ATTENDING PHYSICIAN: John J. Jones
ATTENDING PHYSICIAN NPI: 1122334455
UPIN: U12345
PROCEDURES:
Rev code: 0305 HCPCS: 85025 Billed Amt: 13.39 Units: 1.
Rev code: 0730 HCPCS: 93010 Billed Amt: 76.56 Units: 3.
CLAIM #2:
SUBSCRIBER: Joe Smith
MEMBER ID: 123405074
SUBSCRIBER ADDRESS: 5 Main Street, Anywhere, PA, 17111
DOB: December 12, 1962
SEX: M
PATIENT ACCOUNT #: 756049Q
CLAIM AMOUNT: 50.00
TYPE OF BILL: 131
PRINCIPAL DIAGNOSIS: 300.00
ATTENDING PHYSICIAN: Judy J. Jones
NPI: 9999999999
PROVIDER SPECIALTY: 363LP0200N
PROCEDURES:
Rev code: 0300 HCPCS: 85087 Billed Amt: 50.00 Units: 1.
Transmission Explanation
HEADER
ST*837*987654*005010X292~
ST TRANSACTION SET HEADER
BHT*0019*00*0123*20050630*0932*CH~
BHT BEGINNING OF HIERARCHICAL TRANSACTION
1000A SUBMITTER NAME
NM1*41*2*JONES HOSPITAL*****46*12345~
NM1 SUBMITTER NAME
PER*IC*JANE DOE*TE*1112223333~
PER SUBMITTER EDI CONTACT INFORMATION
1000B RECEIVER NAME
NM1*40*2*TRICARE*****46*99999~
NM1 RECEIVER NAME
2000A BILLING PROVIDER
HL*1**20*1~
HL BILLING PROVIDER HIERARCHICAL LEVEL
PRV*BI*PXC*282N00000X~
PRV BILLING PROVIDER SPECIALTY
2010AA BILLING PROVIDER NAME
NM1*85*2*JONES HOSPITAL*****XX*1234567890~
NM1 BILLING PROVIDER NAME INCLUDING NATIONAL PROVIDER ID
N3*225 MAIN STREET~
N3 BILLING PROVIDER ADDRESS
N4*ANYWHERE*PA*171111234~
N4 BILLING PROVIDER LOCATION
REF*EI*123456789~
REF BILLING PROVIDER TAX IDENTIFICATION NUMBER
2000B SUBSCRIBER HL LOOP
HL*2*1*22*0~
HL SUBSCRIBER HIERARCHICAL LEVEL
SBR*P*18*******CH~
SBR SUBSCRIBER INFORMATION
2010BA SUBSCRIBER NAME LOOP
NM1*IL*1*DOE*JOHN*T***MI*030005074~
NM1 SUBSCRIBER NAME
N3*125 CITY AVENUE~
N3 SUBSCRIBER ADDRESS
N4*CENTERVILLE*PA*17111~
N4 SUBSCRIBER LOCATION
DMG*D8*19681111*M~
DMG SUBSCRIBER DEMOGRAPHIC INFORMATION
2010BB PAYER NAME LOOP
NM1*PR*2*TRICARE*****PI*99999~
NM1 PAYER NAME
2300 CLAIM INFORMATION
CLM*756048Q*89.95***13:A:1**C*Y*Y**********08~
CLM CLAIM LEVEL INFORMATION
CL1***01~
CL1 INSTITUTIONAL CLAIM CODE
HI*BK:3669~
HI PRINCIPAL DIAGNOSIS CODES
HI*BF:4019*BF:79431~
HI OTHER DIAGNOSIS INFORMATION
2310A ATTENDING PROVIDER NAME
NM1*71*1*JONES*JOHN*J***XX*1122334455~
NM1 ATTENDING PROVIDER
REF*1G*U12345~
REF ATTENDING PROVIDER SECONDARY IDENTIFICATION
2400 SERVICE LINE
LX*1~
LX SERVICE LINE COUNTER
SV2*0305*HC:85025*13.39*UN*1~
SV2 INSTITUTIONAL SERVICE
2400 SERVICE LINE
LX*2~
LX SERVICE LINE COUNTER
SV2*0730*HC:93010*76.56*UN*3~
SV2 INSTITUTIONAL SERVICE
2000B SUBSCRIBER HL LOOP
HL*3*1*22*0~
HL SUBSCRIBER HIERARCHICAL LEVEL
SBR*P*18*******CH~
SBR SUBSCRIBER INFORMATION
2010BA SUBSCRIBER NAME LOOP
NM1*IL*1*SMITH*JOE****MI*123405074~
NM1 SUBSCRIBER NAME
N3*5 MAIN STREET~
N3 SUBSCRIBER ADDRESS
N4*ANYWHERE*PA*17111~
N4 SUBSCRIBER LOCATION
DMG*D8*19621210*M~
DMG SUBSCRIBER DEMOGRAPHIC INFORMATION
2010BB PAYER NAME LOOP
NM1*PR*2*TRICARE*****PI*99999~
NM1 PAYER NAME
2300 CLAIM INFORMATION
CLM*756048Q*50***13:A:1**C*Y*Y**********08~
CLM CLAIM LEVEL INFORMATION
CL1***01~
CL1 INSTITUTIONAL CLAIM CODE
HI*BK:30000~
HI PRINCIPAL DIAGNOSIS CODES
2310A ATTENDING PROVIDER NAME
NM1*71*1*JONES*JUDY*J***XX*9999999999~
NM1 ATTENDING PROVIDER
PRV*AT*PXC*363LP0200N~
PRV - ATTENDING PROVIDER SPECIALTY INFORMATION
2400 SERVICE LINE
LX*1~
LX SERVICE LINE COUNTER
SV2*0300*HC:85087*50*UN*1~
SV2 INSTITUTIONAL SERVICE
TRAILER
SE*45*987654~
SE TRANSACTION SET TRAILER