EDI 837 Professional. Version 005010X222A1
Example 5: Ambulance Service
1. Patient is the same person as the subscriber.
2. The provider type is ambulance.
3. The payer is Medicare.
4. The submitter is the same as the provider. The receiver is Medicare.
ISA*00* *00* *ZZ*123456789012345*ZZ*123456789012346*061015*1705*>*00501*000010216*0*T*:
GS*HC*1234567890*9876543210*20061015*1705*20213*X*005010X222A1
ST*837*000017712*005010X222A1
BHT*0019*00*000017712*20050208*1112*CH
NM1*41*2*AAA AMBULANCE SERVICE*****46*376985369
PER*IC*LISA SMITH*TE*3037752536
NM1*40*2*MEDICARE B*****46*123245
HL*1**20*1
PRV*BI*PXC*3416L0300X
NM1*85*2*AAA AMBULANCE SERVICE*****XX*2366554859
N3*12202 AIRPORT WAY
N4*BROOMFIELD*CO*800210021
REF*EI*376985369
HL*2*1*22*0
SBR*P*18*******MB
NM1*IL*1*JONES*SARAH*A***MI*012345678A
N3*1129 REINDEER ROAD
N4*CARR*CO*80612
DMG*D8*19630729*F
NM1*PR*2*MEDICARE PART B*****PI*123245
N3*PO BOX 3543
N4*BALTIMORE*MD*666013543
CLM*051068*766.50***41:B:1*Y*A*Y*Y*P*OA
DTP*439*D8*20050208
CR1*LB*275**A*DH*21****PATIENT IMOBILIZED
CRC*07*Y*04*06*09
CRC*07*N*05*07*08
HI*BK:8628*BF:E8888*BF:9592*BF:8540
NM1*PW*2
N3*1129 REINDEER ROAD
N4*CARR*CO*80612
NM1*45*2
N3*10005 BANNOCK ST
N4*CHEYENNE*WY*82009
LX*1
SV1*HC:A0427:RH*700.00*UN*1.00***1:2:3:4**Y
DTP*472*D8*20050208
QTY*PT*2
REF*6R*1001
NTE*ADD*CARDIAC EMERGENCY
LX*2
SV1*HC:A0425:RH*8.19*UN*21.00***1:2:3:4**Y
DTP*472*D8*20050208
QTY*PT*2
REF*6R*1002
LX*3
SV1*HC:A0422:RH*46.00*UN*1.00***1:2:3:4**Y
DTP*472*D8*20050208
REF*6R*1003
LX*4
SV1*HC:A0382:RH*12.30*UN*1.00***1:2:3:4**Y
DTP*472*D8*20050208
REF*6R*1004
SE*52*000017712
GE*1*20213
IEA*1*000010216
HTML Version
Interchange Control Header
| Authorization Qualifier | 00 |
| Security Qualifier | 00 |
| Interchange ID Qualifier Sender | ZZ |
| Submitter ID | 123456789012345 |
| Interchange ID Qualifier Receiver | ZZ |
| Receiver ID | 123456789012346 |
| Interchange Date | 10/15/2006 |
| InterChange Time (HHMM) | 17:05 |
| Repetition Seperator | > |
| Control Number | 000010216 |
| Acknowledgement Requested | 0 |
| Usage Indicator | T |
Functional Group Header
| Application Sender Code | 1234567890 |
| Application Receiver Code | 9876543210 |
| Group Transaction Date | 10/15/2006 |
| Group Transaction Time (HHMM) | 17:05 |
| Group Control Number | 20213 |
| EDI Version | 005010X222A1 |
Transaction Set Header
| Transaction set | 837 |
| Transaction Control Number | 000017712 |
Hierarchical Transaction
| Application Transaction Number | 000017712 |
| Transaction Date | 02/08/2005 |
| Transaction Time (HHMM) | 11:12 |
| Submitter Entity | Organization |
| Organization Name | AAA AMBULANCE SERVICE |
| Etin Number | 376985369 |
| Contact Name | LISA SMITH |
| Contact Phone | 3037752536 |
| Receiver Name | MEDICARE B |
| Receiver Etin Number | 123245 |
Billing Provider
| Entity Type | 2 |
| Last or Organization Name | AAA AMBULANCE SERVICE |
| Address1 | 12202 AIRPORT WAY |
| City | BROOMFIELD |
| State | CO |
| Zip | 800210021 |
| NPI | 2366554859 |
| Tax ID | 376985369 |
| Taxonomy Code | 3416L0300X |
Subscriber information
| Payer Responsbility | P |
| Insured Relationship | 18 |
| Claim Filling Indicator | MB |
Subscriber Name
| Entity Type | 1 |
| Last or Organization Name | JONES |
| First Name | SARAH |
| Middle Name | A |
| DOB | 07/29/1963 |
| Gender | F |
| Policy No | 012345678A |
| Address1 | 1129 REINDEER ROAD |
| City | CARR |
| State | CO |
| Zip | 80612 |
Payer
| Name | MEDICARE PART B |
| Address1 | PO BOX 3543 |
| City | BALTIMORE |
| State | MD |
| Zip | 666013543 |
| Payer ID | 123245 |
Claim Information
| Claim No | 051068 |
| Billed Amount | 766.50 |
| Claim Type | 1 |
| Provider Sign Indicator | Y |
| Provider Accept Assignment Code | A |
| Benefits Assignment Indicator | Y |
| Release of information | Y |
| Accident Type | Other Accident |
| Accident Date | 02/08/2005 |
ICD Information
| ICD Code 1 | 8628 |
| ICD Code 2 | E8888 |
| ICD Code 3 | 9592 |
| ICD Code 4 | 8540 |
Ambulance Transport Information
| Patient Weight | 275 |
| Patient Weight Unit | LB |
| Transport Reason Code | A |
| Distance | 21 |
| Distance Unit | DH |
| Notes 2 | PATIENT IMOBILIZED |
Claim Ambulance Certification 1
| Yes/No Condition | Y |
| Condition Code 1 | 04 |
| Condition Code 2 | 06 |
| Condition Code 3 | 09 |
Claim Ambulance Certification 2
| Yes/No Condition | N |
| Condition Code 1 | 05 |
| Condition Code 2 | 07 |
| Condition Code 3 | 08 |
Ambulance Pick-up Information
| Address1 | 1129 REINDEER ROAD |
| City | CARR |
| State | CO |
| Zip | 80612 |
Ambulance Drop-up Information
| Address1 | 10005 BANNOCK ST |
| City | CHEYENNE |
| State | WY |
| Zip | 82009 |
Line Item : 1
| Line Item ID | 1001 |
| Procedure Code | A0427 |
| Modifier 1 | RH |
| Units Code | UN |
| Units | 1.00 |
| Charges | 700.00 |
| ICD Pointers | 1,2,3,4 |
| Service From Date | 02/08/2005 |
| Service To Date | 02/08/2005 |
| Emergency Indicator | Y |
| Ambulance Patient Count | 2 |
| Claim Note Type | ADD |
| Claim Note Text | CARDIAC EMERGENCY |
Line Item : 2
| Line Item ID | 1002 |
| Procedure Code | A0425 |
| Modifier 1 | RH |
| Units Code | UN |
| Units | 21.00 |
| Charges | 0.39 |
| ICD Pointers | 1,2,3,4 |
| Service From Date | 02/08/2005 |
| Service To Date | 02/08/2005 |
| Emergency Indicator | Y |
| Ambulance Patient Count | 2 |
Line Item : 3
| Line Item ID | 1003 |
| Procedure Code | A0422 |
| Modifier 1 | RH |
| Units Code | UN |
| Units | 1.00 |
| Charges | 46.00 |
| ICD Pointers | 1,2,3,4 |
| Service From Date | 02/08/2005 |
| Service To Date | 02/08/2005 |
| Emergency Indicator | Y |
Line Item : 4
| Line Item ID | 1004 |
| Procedure Code | A0382 |
| Modifier 1 | RH |
| Units Code | UN |
| Units | 1.00 |
| Charges | 12.30 |
| ICD Pointers | 1,2,3,4 |
| Service From Date | 02/08/2005 |
| Service To Date | 02/08/2005 |
| Emergency Indicator | Y |
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