ASC X12 Version: 008010 | Transaction Set: 278 | TR3 ID: 008010X342
Business Scenario - DME Rental and DME Purchase request with multiple px codes
A Provider submits an initial request for Durable Medical Equipment (DME) rental and DME Purchase for multiple procedure codes using the X342 8010 version.
Inbound Transmission Explanation
ST*278*1001*008010X342~
Submitter transaction Identifier
BHT*0007*13*16139462398*20200624*0734~
HL*1**20*1~
Payer Loop
NM1*X3*2*PAYOR A*****PI*1234567~
HL*2*1*21*1~
Requesting Entity Loop
NM1*1P*1*PCPLASTNAME*PCPFIRSTNAME****XX*1234567899~
Requesting Entity
PER*IC*CONTACT NAME*TE*5556368147*EX*551~
Contact Name and other information
HL*3*2*22*1~
Subscriber Loop
NM1*IL*1*LASTNAME*FIRSTNAME****MI*MEMBERID~
Member Data
DMG*D8*19470701*M~
HL*4*3*EV*1~
Event Loop
UM*HS*I**12:B**E~
Health Services, Initial, Home, Elective
DTP*AAH*D8*20200702~
Event Date
HI*ABF:C189~
Diagnosis
MSG*ADDITIONAL INFORMATION CAN BE PROVIDED IN MSG~
Additional information
NM1*71*1*PROVIDER*ATTENDING****XX*1234567899~
Event Provider role identification
NM1*SJ*2*ABC DME EQUIPMENT*****XX*1234567888~
HL*5*4*SS*0~
Service Loop
UM*HS*I*12~
DTP*472*RD8*20200702-20201002~
SV1*HC:K0813~
PX code= K0813, DME Purchase x1 starting on 7/2/20
HSD*FL*1
HL*6*4*SS*0~
Service Loop
UM*HS*I*18~
DTP*472*RD8*20200702-20201002~
SV1*HC:E0940~
PX code= E0940, DME Rental for 90 Days starting on 7/2/20
HSD*DY*90~
SE*28*1001~
Outbound Transmission Explanation
ST*278*0001*008010X342~
Submitter transaction Identifier
BHT*0007*11*16139462398*20200624*07344807*19~
HL*1**20*1~
Payer Loop
NM1*X3*2*PAYOR A*****PI*1234567~
HL*2*1*21*1~
Requesting Entity Loop
NM1*1P*1*PCPLASTNAME*PCPFIRSTNAME****XX*1234567899~
Requesting Entity Contact Name and other information
HL*3*2*22*1~
Subscriber Loop
NM1*IL*1*LASTNAME*FIRSTNAME****MI*MEMBERID~
Member Data
DMG*D8*19470701*M~
HL*4*3*EV*1~
Event Loop
UM*HS*I**22:B**E~
Health Services, Initial, Home, Elective
HCR*A4**0V~
Certification Action Code
REF*NT*5554772110000000~
Administrative Reference number
DTP*AAH*D8*20200702~
Event Date
HI*ABJ:C189~
Diagnosis
NM1*71*1*PROVIDER*ATTENDING****XX*1234567898~
Event Provider role identification
NM1*SJ*2*ABC DME EQUIPMENT*****XX*1234567888~
HL*5*4*SS*0~
Service Loop
UM*HS*I*12~
HCR*A4**0V~
Certification Action Code
REF*NT*5976434110000000~
Administrative Reference number
DTP*472*RD8*20200702-20201002~
SV1**HC:K0813~
PX code= K0813, DME Purchase x1 starting on 7/2/20
HSD*FL*1~
HL*6*4*SS*0~
Service Loop
UM*HS*I*18~
HCR*A4**0V~
Certification Action Code
REF*NT*5976434110000000~
Administrative Reference number
DTP*472*RD8*20200702-20201002~
SV1*HC:E0940~
PX code= E0940, DME Rental for 90 Days starting on 7/2/20
HSD*DY*90~
SE*32*0001~