Health Care Claim: Dental (X224A3)

ST*837*3456*005010X224A3~
BHT*0019*00*0123*20061123*1023*CH~
NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~
PER*IC*JERRY*TE*7176149999~
NM1*40*2*INSURANCE COMPANY XYZ*****46*66783JJT~
HL*1**20*1~
NM1*85*2*DENTAL ASSOCIATES*****XX*1234567890~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
REF*EI*587654321~
HL*2*1*22*1~
SBR*P********CI~
NM1*IL*1*SMITH*JANE****MI*111223333~
NM1*PR*2*INSURANCE COMPANY XYZ*****PI*66783JJT~
HL*3*2*23*0~
PAT*19~
NM1*QC*1*SMITH*TED~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19920501*M~
CLM*26403774*150***11>B>1*Y*A*Y*I~
DTP*472*D8*20061029~
REF*D9*17312345600006351~
NM1*82*1*KILDARE*BEN****XX*9876543210~
PRV*PE*PXC*1223G0001X~
LX*1~
SV3*AD>D2150*100****1~
TOO*JP*12*M>O~
LX*2~
SV3*AD>D1110*50****1~
SE*31*3456~


Example 1: Commercial Health Insurance

ST*837*0002*005010X224A3~
BHT*0019*00*0123*20061123*1023*CH~
NM1*41*2*PREMIER BILLING SERVICE*****46*567890~
PER*IC*JERRY*TE*7176149999~
NM1*40*2*KEY INSURANCE COMPANY*****46*999996666~
HL*1**20*1~
NM1*85*2*DENTAL ASSOCIATES*****XX*4567890123~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
REF*EI*587654321~
HL*2*1*22*1~
SBR*P********CI~
NM1*IL*1*SMITH*JANE****MI*JS00111223333~
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~
HL*3*2*23*0~
PAT*19~
NM1*QC*1*SMITH*TED~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19920501*M~
CLM*26403774*200***11>B>1*Y*A*Y*I~
DTP*472*D8*20061109~
REF*D9*111222333444~
NM1*82*1*KILDARE*BEN****XX*6789012345~
PRV*PE*PXC*1223P0221X~
LX*1~
SV3*AD>D3320*200****1~
TOO*JP*5~
SE*29*0002~


Example 2a: Claim From Billing Provider to Payer A

ST*837*0123*005010X224A3~
BHT*0019*00*0123*20061123*1023*CH~
NM1*41*2*PREMIER BILLING SERVICE*****46*567890~
PER*IC*JERRY*TE*7176149999~
NM1*40*2*GREAT PRAIRIES HEALTH*****46*123456789~
HL*1**20*1~
NM1*85*2*DENTAL ASSOCIATES*****XX*4567890123~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
REF*EI*587654321~
HL*2*1*22*1~
SBR*S********CI~
NM1*IL*1*SMITH*JACK****MI*T55TY666~
NM1*PR*2*GREAT PRAIRIES HEALTH*****PI*123456789~
HL*3*2*23*0~
PAT*19~
NM1*QC*1*SMITH*TED~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19920501*M~
CLM*26403774*200***11>B>1*Y*A*Y*I~
DTP*472*D8*20061109~
REF*D9*444333222111~
NM1*82*1*KILDARE*BEN****XX*6789012345~
PRV*PE*PXC*1223P0221X~
SBR*P*19*******CI~
CAS*PR*1*50*1~
AMT*D*150~
OI***Y***I~
NM1*IL*1*SMITH*JANE****MI*JS00111223333~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~
DTP*573*D8*20061122~
LX*1~
SV3*AD>D3320*200****1~
TOO*JP*5~
SE*38*0123~


Example 2b: Claim from Billing Provider to Payer B

ST*837*0321*005010X224A3~
BHT*0019*00*0123*20061123*1023*CH~
NM1*41*2*ABC CLEARINGHOUSE*****46*ABC123~
PER*IC*JERRY*TE*7176149999~
NM1*40*2*KEY INSURANCE COMPANY*****46*999996666~
HL*1**20*1~
PRV*BI*PXC*1223G0001X~
NM1*85*1*JOHN*DOE****XX*2345678901~
N3*123 TOOTH DRIVE~
N4*MIAMI*FL*33411~
REF*EI*587654321~
HL*2*1*22*0~
SBR*P*18*******CI~
NM1*IL*1*SMITH*JANE****MI*111223333~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19430501*F~
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~
CLM*SMITH878*750***11>B>1*Y*A*Y*I**********PB~
PWK*RB*BM***AC*SMITHJANE11122333~
REF*D9*123123123~
LX*1~
SV3*AD>D2750*750***I*1~
TOO*JP*13~
SE*25*0321~


Example 3: Predetermination of Benefits

ST*837*0322*005010X224A3~
BHT*0019*00*0123*20061123*1023*CH~
NM1*41*2*JOHN DOE*****46*940001~
PER*IC*SALLY*TE*7175555555~
NM1*40*2*KEY INSURANCE COMPANY*****46*999996666~
HL*1**20*1~
PRV*BI*PXC*1223G0001X~
NM1*85*1*JOHN*DOE****XX*2345678901~
N3*123 TOOTH DRIVE~
N4*MIAMI*FL*33411~
REF*EI*587654321~
HL*2*1*22*1~
SBR*P********CI~
NM1*IL*1*SMITH*JANE****MI*111223333~
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~
HL*3*2*23*0~
PAT*19~
NM1*QC*1*SMITH*TED~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19911029*M~
CLM*SMITH788*4000***11>B>1*Y*A*Y*I~
DTP*452*D8*20061115~
DN1*36~
LX*1~
SV3*AD>D8080*4000****1~
SE*27*0322~


Example 4: Orthodontic Treatment Plan

ST*837*0001*005010X224A3~
BHT*0019*00*1000002*20140305*0745*CH~
NM1*41*2*XYZ CLEARINGHOUSE*****46*321123~
PER*IC*XYZ CLEARINGHOUSE, INC.*TE*8005551212*EX*123*EM*PRODUCTIONSUPPORT@XYZCLEARINGHOUSE.COM~
NM1*40*2*ACME DENTAL PAYER*****46*12345~
HL*1**20*1~
NM1*85*2*ANYTOWN DENTAL*****XX*1234567984~
N3*926 MAIN ST~
N4*ANYTOWN*FL*327147244~
REF*EI*222222222~
PER*IC*ANYTOWN DENTAL*TE*4075551213~
HL*2*1*22*0~
SBR*P*18*12345687******CI~
NM1*IL*1*SUBLAST*SUBFIRST*M***MI*123456~
N3*654 ANYWHERE DR~
N4*ANYTOWN*FL*32000~
DMG*D8*19710101*M~
NM1*PR*2*BLUE EXAMPLE*****PI*11111~
CLM*119033233*293.19***11>B>1*Y*C*Y*Y~
PWK*OZ*EL***AC*NEA123456798~
REF*D9*0001958960000001~
NM1*82*1*RENDERLAST*RENDERFIRST****XX*1234567893~
PRV*PE*PXC*1223G0001X~
LX*1~
SV3*AD>D7140*150~
TOO*JP*31~
REF*6R*01~
LX*2~
SV3*AD>D0140*130~
REF*6R*02~
LX*3~
SV3*AD>D9985*13.19~
REF*6R*03~
SE*34*0001~


Example 5: Sales Tax

ST*837*0001*005010X224A3~
BHT*0019*00*1000002*20140305*0745*CH~
NM1*41*2*XYZ CLEARINGHOUSE*****46*321123~
PER*IC*XYZ CLEARINGHOUSE, INC.*TE*8005551212*EX*123*EM*PRODUCTIONSUPPORT@XYZCLEARINGHOUSE.COM~
NM1*40*2*ACME DENTAL PAYER*****46*12345~
HL*1**20*1~
NM1*85*2*ANYTOWN DENTAL*****XX*1234567984~
N3*926 MAIN ST~
N4*ANYTOWN*FL*327147244~
REF*EI*222222222~
PER*IC*ANYTOWN DENTAL*TE*4075551213~
HL*2*1*22*0~
SBR*P*18*12345687******CI~
NM1*IL*1*SUBLAST*SUBFIRST*M***MI*123456~
N3*654 ANYWHERE DR~
N4*ANYTOWN*FL*32000~
DMG*D8*19710101*M~
NM1*PR*2*ACME DENTAL PAYER*****PI*11111~
CLM*1191*900***11>B>1*Y*C*Y*Y~
PWK*OZ*EL***AC*NEA123456798~
REF*D9*0001958960000001~
NM1*82*1*RENDERLAST*RENDERFIRST****XX*1234567893~
PRV*PE*PXC*1223G0001X~
LX*1~
SV3*AD>D5214*900~
TOO*JP*31~
TOO*JP*30~
TOO*JP*21~
TOO*JP*19~
TOO*JP*18~
SE*31*0001~


Example 6: Multiple Tooth Numbers

ST*837*0001*005010X224A3~
BHT*0019*00*1000002*20140305*0745*CH~
NM1*41*2*XYZ CLEARINGHOUSE*****46*321123~
PER*IC*XYZ CLEARINGHOUSE, INC.*TE*8005551212*EX*123*EM*PRODUCTIONSUPPORT@XYZCLEARINGHOUSE.COM~
NM1*40*2*ACME DENTAL PAYER*****46*12345~
HL*1**20*1~
NM1*85*2*ANYTOWN DENTAL*****XX*1234567984~
N3*926 MAIN ST~
N4*ANYTOWN*FL*327147244~
REF*EI*222222222~
PER*IC*ANYTOWN DENTAL*TE*4075551213~
HL*2*1*22*0~
SBR*P*18*12345687******CI~
NM1*IL*1*SUBLAST*SUBFIRST*M***MI*123456~
N3*654 ANYWHERE DR~
N4*ANYTOWN*FL*32000~
DMG*D8*19710101*M~
NM1*PR*2*BLUE EXAMPLE*****PI*11111~
CLM*22*44***11>B>1*Y*C*Y*Y~
DTP*472*D8*20140303~
REF*D9*0001958960000001~
HI*BK>5273~
NM1*82*1*RENDERLAST*RENDERFIRST****XX*1234567893~
PRV*PE*PXC*1223G0001X~
REF*0B*321654~
LX*1~
SV3*AD>D0230*44***I*4~
REF*6R*123456-01~
SE*29*0001~


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X12 837 Health Care Claim: Dental (X224A3)