Patient is a different person than the Subscriber.
if the patient is a different person than the Subscriber, then we need provide patient details in the EDI 837 along with subscriber information. Loop 2000C and 2010CA will be added
In Medicare, the Subscriber is always the Patient. Therefore, loop 2000C and loop 2010CA should not be reported or a rejection will occur on the 277 Claims Acknowledgement (277CA).
Here is an example for EDI 837 for Patient is a different person than the Subscriber. In this example , 01 stands for Spouse in the following line
PAT*01
Please note : All the information used in this example are dummy data.
ISA*00* *00* *ZZ*111134 *ZZ*zirmed *220528*0405*^*00501*814000000*0*P*:
GS*HC*111134*zirmed*20220528*0405*814000000*X*005010X222A1
ST*837*0001*005010X222A1
BHT*0019*00*0001*20220528*0405*CH
NM1*41*2*Demo Practice*****46*111134
PER*IC*John Richard*TE*2025550170*FX*2025550179
NM1*40*2*zirmed*****46*zirmed
HL*1**20*1
PRV*BI*PXC*207NP0225X
NM1*85*2*Demo Clinic*****XX*1211111111
N3*319 16th Ave*APT E10
N4*WestField*NY*14787
REF*EI*222222222
NM1*87*2
N3*21208 Creekside Dr
N4*Leander*TX*20720
HL*2*1*22*1
SBR*P********ZZ
NM1*IL*1*Aliza*Bins*D***MI*XYZ312322
N3*4229 SNIDER STREET
N4*Englewood*CO*80112
DMG*D8*19550607*M
NM1*PR*2*AETNA*****PI*60054
N3*PO BOX 14770
N4*Lexington*KY*12345
HL*3*2*23*0
PAT*01
NM1*QC*1*Misty*MOSLEY
N3*724 Central Ave SE
N4*Sheffield*IA*10475
DMG*D8*19550612*F
CLM*124309*120***11:B:1*Y*A*Y*Y*P
HI*ABK:A032
NM1*82*1*Sean*Smith****XX*6565656565
NM1*77*2*NY Office*****XX*1336177328
N3*5081 Tellus. Avenue
N4*White Plains*NY*809051232
LX*1
SV1*HC:99214*120*UN*1*11**1
DTP*472*D8*20190604
REF*6R*75982
SE*40*0001
GE*1*814000000
IEA*1*814000000
HTML Version
Interchange Control Header
| Authorization Qualifier | 00 |
| Security Qualifier | 00 |
| Interchange ID Qualifier Sender | ZZ |
| Submitter ID | 111134 |
| Interchange ID Qualifier Receiver | ZZ |
| Receiver ID | zirmed |
| Interchange Date | 05/28/2022 |
| InterChange Time (HHMM) | 04:05 |
| Repetition Seperator | ^ |
| Control Number | 814000000 |
| Acknowledgement Requested | 0 |
| Usage Indicator | P |
Functional Group Header
| Application Sender Code | 111134 |
| Application Receiver Code | zirmed |
| Group Transaction Date | 05/28/2022 |
| Group Transaction Time (HHMM) | 04:05 |
| Group Control Number | 814000000 |
| EDI Version | 005010X222A1 |
Transaction Set Header
| Transaction set | 837 |
| Transaction Control Number | 0001 |
Hierarchical Transaction
| Application Transaction Number | 0001 |
| Transaction Date | 05/28/2022 |
| Transaction Time (HHMM) | 0405 |
| Submitter Entity | Organization |
| Organization Name | Demo Practice |
| Etin Number | 111134 |
| Contact Name | John Richard |
| Contact Phone | 2025550170 |
| Contact Fax | 2025550179 |
| Receiver Name | zirmed |
| Receiver Etin Number | zirmed |
Billing Provider
| Entity Type | 2 |
| Last or Organization Name | Demo Clinic |
| Address1 | 319 16th Ave |
| Address2 | APT E10 |
| City | WestField |
| State | NY |
| Zip | 14787 |
| NPI | 1211111111 |
| Tax ID | 222222222 |
| Taxonomy Code | 207NP0225X |
Billing Provider Pay to Address
| Entity Type | 2 |
| Address1 | 21208 Creekside Dr |
| City | Leander |
| State | TX |
| Zip | 20720 |
Subscriber information
| Payer Responsbility | P |
| Insured Relationship | 01 |
| Claim Filling Indicator | ZZ |
Subscriber Name
| Entity Type | 1 |
| Last or Organization Name | Aliza |
| First Name | Bins |
| Middle Name | D |
| DOB | 06/07/1955 |
| Gender | M |
| Policy No | XYZ312322 |
| Address1 | 4229 SNIDER STREET |
| City | Englewood |
| State | CO |
| Zip | 80112 |
Payer
| Name | AETNA |
| Address1 | PO BOX 14770 |
| City | Lexington |
| State | KY |
| Zip | 12345 |
| Payer ID | 60054 |
Patient Information
| Last Name | Misty |
| First Name | MOSLEY |
| DOB | 06/12/1955 |
| Gender | F |
| Address1 | 724 Central Ave SE |
| City | Sheffield |
| State | IA |
| Zip | 10475 |
Claim Information
| Claim No | 124309 |
| Billed Amount | 120 |
| Claim Type | 1 |
| Provider Sign Indicator | Y |
| Provider Accept Assignment Code | A |
| Benefits Assignment Indicator | Y |
| Release of information | Y |
| Patient Signature Code | P |
ICD Information
| ICD Code 1 | A032 |
Rendering Provider
| Entity Type | 1 |
| Last or Organization Name | Sean |
| First Name | Smith |
| NPI | 6565656565 |
Facility
| Name | NY Office |
| Address1 | 5081 Tellus. Avenue |
| City | White Plains |
| State | NY |
| Zip | 809051232 |
| NPI | 1336177328 |
Line Item : 1
| Line Item ID | 75982 |
| Procedure Code | 99214 |
| Units Code | UN |
| Units | 1 |
| Charges | 120.00 |
| ICD Pointers | 1 |
| Service From Date | 06/04/2019 |
| Service To Date | 06/04/2019 |
| POS | 11 |
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