ASC X12 Version: 005010 | Transaction Set: 837 | TR3 ID: 005010X292
Example 04: 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 and the subscriber are the same. In this situation, the hospital 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.
PATIENT/SUBSCRIBER: JAMES A SMITH
ADDRESS: 934 North Street, Columbus, OH 432150000
SEX: M
DATE OF BIRTH: 10/15/1962
EMPLOYER: TREE TRIMMING SERVICE
GROUP NUMBER: 34561W
MEMBER ID: 34902390F
PATIENT CONTROL NUMBER: W392-49141
SUBMITTER: Regional PPO Network
SUBMITTER ID: 123456789
RECEIVER: Conservative Insurance
RECEIVER ID: 000110002
DESTINATION PAYER: Conservative Insurance
PAYER ID NUMBER: 00123
BILLING PROVIDER: LOCAL HOSPITAL
ADDRESS: 3423 Small Street, Columbus, OH 432150000
NATIONAL PROVIDER ID (NPI): 1122334455
TAX IDENTIFICATION NUMBER (TIN): 111-00-2222
RENDERING PROVIDER: Dawn Rivers
NATIONAL PROVIDER ID (NPI): 2244224455
REPRICING INFORMATION:
TOTAL CHARGES: $14.84
TOTAL REPRICED AMOUNT: $0
SAVINGS AMOUNT: $0
TIN FOR THE REPRICING ORGANIZATION: 333001234
Transmission Explanation
HEADER
ST*837*1024*005010X292~
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*LOCAL HOSPITAL*****XX*1122334455~
NM1 BILLING PROVIDER NAME INCLUDING NATIONAL PROVIDER ID
N3*3423 SMALL STREET~
N3 BILLING PROVIDER ADDRESS
N4*COLUMBUS*OH*432150000~
N4 BILLING PROVIDER LOCATION
REF*EI*111002222~
REF BILLING PROVIDER TAX IDENTIFICATION NUMBER
2000B SUBSCRIBER HL LOOP
HL*2*1*22*0~
HL SUBSCRIBER HIERARCHICAL LEVEL
SBR*P*18*34561W******CI~
SBR SUBSCRIBER INFORMATION
2010BA SUBSCRIBER NAME LOOP
NM1*IL*1*SMITH*JAMES*A***MI*34902390F~
NM1 SUBSCRIBER NAME
N3*934 NORTH STREET~
N3 SUBSCRIBER ADDRESS
N4*COLUMBUS*OH*432150000~
N4 SUBSCRIBER LOCATION
DMG*D8*19621015*M~
DMG SUBSCRIBER DEMOGRAPHIC INFORMATION
2010BB PAYER NAME LOOP
NM1*PR*2*CONSERVATIVE INSURANCE*****PI*0012~
NM1 PAYER NAME
2300 CLAIM INFORMATION
CLM*W392-49141*14.84***13:A:1**A*Y*Y**********08~
CLM CLAIM LEVEL INFORMATION
CL1**1*01~
CL1 INSTITUTIONAL CLAIM CODE
REF*9A*459804390823~
REF REPRICED CLAIM NUMBER
REF*D9*32423466233~
REF CLEARING HOUSE CLAIM NUMBER (ASSIGNED BY THE CLEARING HOUSE WHEN TRANSMITTING TO THE REPRICER)
HI*BK:53081~
HI HEALTH CARE DIAGNOSIS CODES
HCP*00*0**333001234*********T1~
HCP HEALTH CARE PRICING - OUT OF NETWORK INFORMATION
2310A ATTENDING PROVIDER NAME
NM1*71*1*RIVERS*DAWN****XX*2244224455~
NM1 ATTENDING PROVIDER
2400 SERVICE LINE
LX*1~
LX SERVICE LINE COUNTER
SV2*0301*HC:82270*14.84*UN*1~
SV2 INSTITUTIONAL SERVICE
TRAILER
SE*27*1024~
SE TRANSACTION SET TRAILER