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Sita Kapoor Infotech Global Inc. 100 Franklin Square Dr. Somerset, NJ 08873 sk@igiusa

Profession Claim example 837 Professional ASC x12N (004010x098A1). Sita Kapoor Infotech Global Inc. 100 Franklin Square Dr. Somerset, NJ 08873 sk@igiusa.com. September 24, 2003. Claim Information, in English. SUBSCRIBER/PATIENT: Ted Smith ADDRESS: 236 N. Main St., Miami, FL 33413

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Sita Kapoor Infotech Global Inc. 100 Franklin Square Dr. Somerset, NJ 08873 sk@igiusa

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  1. Profession Claim example 837 Professional ASC x12N (004010x098A1) Sita Kapoor Infotech Global Inc. 100 Franklin Square Dr. Somerset, NJ 08873 sk@igiusa.com September 24, 2003

  2. Claim Information, in English SUBSCRIBER/PATIENT: Ted Smith ADDRESS: 236 N. Main St., Miami, FL 33413 TELEPHONE NUMBER: 305-555-1111 SEX: Male DOB: 05/01/1948 GROUP#: 12312-A SSN: 000-22-1111 DESTINATION PAYER: ACS BENEFITS SERVICES PAYOR ADDRESS: P O Box 2181, Somerset, NJ 08853 PAYER ID NUMBER: 00520

  3. Claim Information, in HCFA 1500

  4. Claim Information, in English BILLING PROVIDER/SENDER: Michael Brenett ADDRESS: ASSAD, WASSAD NJ 12121212 TIN: 111753453 RENDERING PROVIDER: Michael Brenett Payer Provider ID: 52054 UPIN ID C68426 PATIENT ACCOUNT NUMBER: SM-192619 CASE: Office Visit DOS=03/21/2003. POS=Office SERVICES RENDERED: Office first visit = $40.00 Next CPT Code = $15.00 Next CPT Code = $35.00

  5. Claim Information, in HCFA 1500 V1506

  6. Claim Information, in x12 BHT*0019*00*20030923*20030923*1933*CH~ REF*87*004010X098DA1~ NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*Z9988~ PER*IC*MNJY*TE*9089463571~ NM1*40*2*BCBS*****46*00520~ HL*1**20*1~ NM1*85*1*BERNETT*MICHAEL****24*111753453~ N3*ASSAD~ N4*WSDSAD*NJ*12121212~ REF*1C*52054~

  7. Claim Information, in x12 HL*2*1*22*0~ SBR*P*18**ACS BENEFITS SERVICES*****16~ NM1*IL*1*SMITH*TED****MI*000221111~ N3*2316 N. MAIN STREET~ N4*MIAMI*FL*33413~ DMG*D8*19480501*M~ REF*1G*12312-A~ NM1*PR*2*ACS BENEFITS SERVICES*****PI*00520~ N3*P O BOX 2181~ N4*SOMERSET*NJ*08853~ CLM*SM192619*55***22::1*Y*A*Y*A*C~ DTP*431*D8*20030321~ HI*BF:V1506~ NM1*82*1*BERNETT*MICHAEL****ZZ*52054~ PRV*PE*ZZ*282N00000X~ REF*1G*C68426~ LX*1~ SV1*HC:99213*40*UN*1*40**1**Y******0~ DTP*472*RD8*20030321-20030321~ LX*2~ SV1*HC:99214*40*UN*1*15**1**Y******0~ DTP*472*D8*20030321~ LX*3~ SV1*HC:99215*40*UN*1*30**1**Y******0~ DTP*472*RD8*20030321-20030323~

  8. Provider Information HL*1**20*1~ NM1*85*1*BERNETT*MICHAEL****24*111753453~ N3*ASSAD~ N4*WSDSAD*NJ*12121212~ REF*1C*52054~ 52054 C68426

  9. Subscriber Information HL*2*1*22*0~ SBR*P*18**ACS BENEFITS SERVICES*****16~ NM1*IL*1*SMITH*TED****MI*000221111~ N3*2316 N. MAIN STREET~ N4*MIAMI*FL*33413~ DMG*D8*19480501*M~ NM1*PR*2*ACS BENEFITS SERVICES*****PI*00520~ N3*P O BOX 2181~ N4*SOMERSET*NJ*08853~

  10. Subscriber Information HL*2*1*22*0~ SBR*P*18**ACS BENEFITS SERVICES*****16~ NM1*IL*1*SMITH*TED****MI*000221111~ N3*2316 N. MAIN STREET~ N4*MIAMI*FL*33413~ DMG*D8*19480501*M~ REF*1G*12312-A~ NM1*PR*2*ACS BENEFITS SERVICES*****PI*00520~ N3*P O BOX 2181~ N4*SOMERSET*NJ*08853~

  11. Patient Information The Subscriber is the Patient The Patient Loop will not be mapped

  12. Subscriber Payer Information HL*2*1*22*0~ SBR*P*18**ACS BENEFITS SERVICES*****16~ NM1*IL*1*SMITH*TED****MI*000221111~ N3*2316 N. MAIN STREET~ N4*MIAMI*FL*33413~ DMG*D8*19480501*M~ REF*1G*12312-A~ NM1*PR*2*ACS BENEFITS SERVICES*****PI*00520~ N3*P O BOX 2181~ N4*SOMERSET*NJ*08853~

  13. Claim Information CLM*SM192619*85***11::1*Y*A*Y*A*C~ DTP*431*D8*20030321~ HI*BF:V1506~ NM1*82*1*BERNETT*MICHAEL****24*52054~ PRV*PE*ZZ*282N00000X~ REF*1G*C68426~ Original

  14. Claim Information V1506 Office Visit Original CLM*SM192619*85***11::1*Y*A*Y*A*C~ DTP*431*D8*20030321~ HI*BF:V1506~ NM1*82*1*BERNETT*MICHAEL****24*52054~ PRV*PE*ZZ*282N00000X~ REF*1G*C68426~ Original

  15. Service Line Information LX*1~ SV1*HC:99213*40*UN*1*06**1**Y******0~ DTP*472*RD8*20030321-20030321~ LX*2~ SV1*HC:99214*40*UN*1*06**1**Y******0~ DTP*472*D8*20030321~ LX*3~ SV1*HC:99215*40*UN*2*06**1**Y******0~ DTP*472*RD8*20030321-20030323~

  16. EDI Claim in the x12N format BHT*0019*00*20030923*20030923*1933*CH~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*Z9988~PER*IC*MNJY*TE*9089463571~NM1*40*2*BCBS*****46*00520~HL*1**20*1~NM1*85*1*BERNETT*MICHAEL****24*111753453~N3*ASSAD~N4*WSDSAD*NJ*12121212~REF*1C*52054~HL*2*1*22*0~SBR*P*18*000221111*ACS BENEFITS SERVICES*****MB~NM1*IL*1*SMITH*TEX*S***MI*000221111~N3*2316 N. MAIN STREET~N4*MIAMI*FL*33413~REF*87*3053331111~DMG*D8*19480501*M~NM1*PR*2*ACS BENEFITS SERVICES*****PI*00520~N3*P O BOX 1181~N4*SOMERSET*NJ*08853~CLM*1154748*55***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030321~HI*BF:V1506~NM1*82*1*BERNETT*MICHAEL****24*52054~PRV*PE*ZZ*282N00000X~REF*1G*C68426~LX*1~SV1*HC:99213*40*UN*1*40**1**Y******0~DTP*472*RD8*20030321-20030321~LX*2~SV1*HC:99214*40*UN*1*15**1**Y******0~DTP*472*D8*20030321~LX*3~SV1*HC:99215*40*UN*1*30**1**Y******0~DTP*472*RD8*20030321-20030323~

  17. EDI Transaction Control Segments

  18. Control Envelopes Control Envelopes • ISA / IEA • Interchange envelope • GS / GE • Functional group envelope • ST / SE • Transaction set envelope

  19. HCFA 1500 EQUALS Functions of the Transaction Set (ST/SE) Control Envelope (One Business Document)

  20. Control Envelope EDI Transaction Set with Control Envelope ~ 01 ST * 02 * Transaction Set EDI Data - Claim #1 ~ 02 SE * * 01

  21. Transaction Set (ST/SE) Control Envelope ST*837*1234~ BHT*0019*00*20030923*20030923*1933*CH~ REF*87*004010X098DA1~ NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*ZZZ98576~ PER*IC*MARY*TE*7322710600~ NM1*40*2*BCBS*****46*980005420~ HL*1**20*1~ NM1*85*2*IGI HOSPITAL & NURSING HOME*****24*980S57F237~ {cont} SE*14*1234~ ST*837*1235~ BHT*0019*00*20030923*20030923*1933*RP~ REF*87*004010X098DA1~ NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*ZZZ98576~ PER*IC*MARY*TE*7322710600~ NM1*40*2*BCBS*****46*980005420~ HL*1**20*1~ NM1*85*2*IGI HOSPITAL & NURSING HOME*****24*980S57F237~ {cont} SE*14*1235~

  22. Functional Group (GS/GE) Control Envelope HCFA 1500 HCFA 1500 HCFA 1500 To: Payer A Claims Payable Functional Groups EQUALS To: Payer A Claims Reporting Transaction Sets

  23. Control Envelope GS * * 01 02 03 04 F U N C T I O N A L * * * ~ 05 06 07 08 * * * ST EDI Data – Claims (charges) Trans Set SE ST Trans Set EDI Data – Claims (reporting) SE 01 02 ~ GE * *

  24. Functional Group (GS/GE) Control Envelope GS*HC*ZZ576*00520*20030923*1933*20030923*X*004010X098A1~ ST*837*1234~ BHT*0019*00*20030923*20030923*1933*CH~ REF*87*004010X098DA1~ NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*ZZZ98576~ PER*IC*MARY*TE*7322710600~ SE*1000*1234~ ST*837*1235~ BHT*0019*00*20030923*20030923*1933*RP~ REF*87*004010X098DA1~ NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*ZZZ98576~ PER*IC*MARY*TE*7322710600~ SE*26*1234~ GE*2*20030923~

  25. EXPRESS DELIVERY Eligibility Information HCFA 1500 HCFA 1500 Sender: Dr Jones 345 lane NJ 99893 Receiver: BSBC OF CA 232 LN CA 09393 Tracking #: 0000000001 0 77975 02176 7 Interchange (ISA/IEA) Control Envelope To: Payer A Claims Payable Interchange Functional Groups To: Payer A Member Enrollment Transaction Sets

  26. Control Envelope ISA * * * * * * * * 01 02 03 04 05 06 07 08 I N T E R C H A N G E * * * * * * * * ~ 09 10 11 12 13 14 15 16 GS ST F U N C T I O N A L G R O U P EDI Data – HCFA SET #1 Trans Set SE ST EDI Data – HCFA SET #2 Trans Set GE SE ST GS EDI Data Eligibility Info #1 Trans Set GE SE IEA * * ~ 01 02

  27. Interchange (ISA/IEA) Control Envelope ISA*00*0000000001*00*0000000001*ZZ*E1576 *30*00520 *200309*1933*U*00401*000000001*1*T*:~ GS*HC*E1576*00520*20030923*1933*20030923*X*004010X098A1~ ST*837*1234~ BHT*0019*00*20030923*20030923*1933*CH~ REF*87*004010X098DA1~ NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*ZZZ98576~ PER*IC*MARY*TE*7322710600~ SE*1000*1234~ ST*837*1235~ BHT*0019*00*20030923*20030923*1933*RP~ REF*87*004010X098DA1~ NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*ZZZ98576~ PER*IC*MARY*TE*7322710600~ SE*26*1234~ GE*2*20030923~ IEA*1*000000001~

  28. EDI Claim in the x12N format ISA*00*0000000001*00*0000000001*ZZ*E1576 *30*00520 *200309*1933*U*00401*000000001*1*T*:~GS*HC*E1576*00520*20030923*1933*20030923*X*004010X098A1~ST*837*00001~BHT*0019*00*20030923*20030923*1933*CH~REF*87*004010X098DA1~NM1*41*2*DEWITT HOSPITAL & NURSING HOME*****46*E1576~PER*IC*SUSAN*TE*8709463571~NM1*40*2*BCBS*****46*00520~HL*1**20*1~NM1*85*2*DEWITT HOSPITAL & NURSING HOME*****24*57237~N3*P.O. BOX 32~N4*DE WITT*AR*72042~REF*1C*57237~HL*2*1*22*0~SBR*P*18*XCAV71748*AR BLUE CROSS/BLUE SHIELD*****MB~PAT*~NM1*IL*1*DEBERRY*WILLIAM*S***MI*XCAV71748~N3*90 SAM DEBERRY RD~N4*DEWITT*AR*720420000~DMG*D8*19530817*M~NM1*PR*2*AR BLUE CROSS/BLUE SHIELD*****PI*00520~N3*P O BOX 2181~N4*LITTLE ROCK*AR*722030000~CLM*1154748*55***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030726~HI*BK:9895*BF:72981*BF:E9053*BF:V1506~NM1*DN*1*BURLESON*STAN*W***24*D04410~REF*1B*X~NM1*82*1*GUSTAVUS*JOHN*L***24*52054~PRV*PE*ZZ*282N00000X~REF*1G*C68426~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99282*55*UN*1*22**1:2:3:4**Y******0~DTP*472*RD8*20030726-20030726~HL*3*1*22*0~SBR*P*18*431356390*AMCO/AHA-1ST SOURCE REPRICI*****MB~PAT*~NM1*IL*1*JAMES*KELLY****MI*431356390~N3*813 W GIBSON~N4*DEWITT*AR*72042~DMG*D8*19721113*F~NM1*PR*2*AMCO/AHA-1ST SOURCE REPRICI*****PI*00520~N3*P O BOX 2181~N4*LITTLE ROCK*AR*722032181~CLM*1154754*55***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030726~HI*BK:7840*BF:78701~NM1*DN*1*GUSTAVUS*JOHN*L***24*C68426~REF*1B*52054~NM1*82*1*GUSTAVUS*JOHN*L***24*52054~PRV*PE*ZZ*282N00000X~REF*1G*C68426~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99282*55*UN*1*22**1:2**Y******0~DTP*472*RD8*20030726-20030726~HL*4*1*22*0~SBR*P*18*HIP431310803-00*BLUE ADVANTAGE ADMINISTRATO*****MB~PAT*~NM1*IL*1*PADGETT*DELORES****MI*HIP431310803-00~N3*P.O.BOX 56~N4*ETHEL*AR*72048~DMG*D8*19400405*F~NM1*PR*2*BLUE ADVANTAGE ADMINISTRATO*****PI*00520~N3*P.O. BOX 1460~N4*LITTLE ROCK*AR*722030000~CLM*1154731*100***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030725~HI*BK:78902*BF:78701*BF:7936*BF:V1005~NM1*DN*1*GUSTAVUS*JOHN*L***24*C68426~REF*1B*52054~NM1*82*1*GUSTAVUS*JOHN*L***24*52054~PRV*PE*ZZ*282N00000X~REF*1G*C68426~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99284*100*UN*1*22**1:2:3:4**Y******0~DTP*472*RD8*20030725-20030725~HL*5*1*22*0~SBR*P*18*XCJ990004117*AR BLUE CROSS/BLUE SHIELD*****MB~PAT*~NM1*IL*1*ESTES*LARRY****MI*XCJ990004117~NM1*PR*2*AR BLUE CROSS/BLUE SHIELD*****PI*00520~N3*P O BOX 2181~N4*LITTLE ROCK*AR*722030000~CLM*853101*198***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030730~HI*BK:41091*BF:3051~NM1*DN*1*TRACY*WALLACE*LEE***24*E02920~REF*1B*50594~NM1*82*1*TRACY*WALLACE*LEE***24*50594~PRV*PE*ZZ*282N00000X~REF*1G*E02920~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99223*198*UN*1*22**1:2**Y******0~DTP*472*RD8*20030730-20030730~HL*6*1*22*0~SBR*P*18*XCSL83633*AR BLUE CROSS/BLUE SHIELD*****MB~PAT*~NM1*IL*1*FLY*CYNTHIA****MI*XCSL83633~NM1*PR*2*AR BLUE CROSS/BLUE SHIELD*****PI*00520~N3*P O BOX 2181~N4*LITTLE ROCK*AR*722030000~CLM*1154898*75***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030801~HI*BK:5920~NM1*DN*1*TRACY*WALLACE*LEE***24*E02920~REF*1B*50594~NM1*82*1*TRACY*WALLACE*LEE***24*50594~PRV*PE*ZZ*282N00000X~REF*1G*E02920~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99283*75*UN*1*22**1**Y******0~DTP*472*RD8*20030801-20030801~HL*7*1*22*0~SBR*P*18*XCAC77095*AR BLUE CROSS/BLUE SHIELD*****MB~PAT*~NM1*IL*1*WRINKLE*KENNETH*G***MI*XCAC77095~N3*BOX 471~N4*GILLETT*AR*720550000~DMG*D8*19401206*M~NM1*PR*2*AR BLUE CROSS/BLUE SHIELD*****PI*00520~N3*P O BOX 2181~N4*LITTLE ROCK*AR*722030000~CLM*1154810*35***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030728~HI*BK:9181*BF:E9289~NM1*DN*1*TRACY*WALLACE*LEE***24*E02920~REF*1B*50594~NM1*82*1*TRACY*WALLACE*LEE***24*50594~PRV*PE*ZZ*282N00000X~REF*1G*E02920~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99281*35*UN*1*22**1:2**Y******0~DTP*472*RD8*20030728-20030728~HL*8*1*22*0~SBR*P*18*431-35-6390*AMCO/AHA-1ST SOURCE REPRICI*****MB~PAT*~NM1*IL*1*JAMES*KELLY****MI*431-35-6390~N3*813 W GIBSON~N4*DEWITT*AR*72042~DMG*D8*19721113*F~NM1*PR*2*AMCO/AHA-1ST SOURCE REPRICI*****PI*00520~N3*P O BOX 2181~N4*LITTLE ROCK*AR*722032181~CLM*1153840*75***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030606~HI*BK:4660~NM1*DN*1*TRACY*WALLACE*LEE***24*E02920~REF*1B*50594~NM1*82*1*TRACY*WALLACE*LEE***24*50594~PRV*PE*ZZ*282N00000X~REF*1G*E02920~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99283*75*UN*1*22**1**Y******0~DTP*472*RD8*20030606-20030606~HL*9*1*22*0~SBR*P*18*XCP990105122*FIRST SOURCE*****MB~PAT*~NM1*IL*1*SIEBER*LESTER****MI*XCP990105122~N3*1206 S ADAMS~N4*DEWITT*AR*720420000~DMG*D8*19991104*M~NM1*PR*2*FIRST SOURCE*****PI*00520~N3*PO BOX 2181~N4*LITTLE ROCK*AR*720990000~CLM*1155171*55***23::1*Y*A*Y*A*C******P~DTP*431*D8*20030815~HI*BK:9895*BF:7295*BF:E9053~NM1*DN*1*TRACY*WALLACE*LEE***24*E02920~REF*1B*50594~NM1*82*1*TRACY*WALLACE*LEE***24*50594~PRV*PE*ZZ*282N00000X~REF*1G*E02920~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99282*55*UN*1*23**1:2:3**Y******0~DTP*472*RD8*20030815-20030815~HL*10*1*22*0~SBR*P*18*XCP990105122*FIRST SOURCE*****MB~PAT*~NM1*IL*1*SIEBER*LESTER****MI*XCP990105122~NM1*PR*2*FIRST SOURCE*****PI*00520~N3*PO BOX 2181~N4*LITTLE ROCK*AR*720990000~CLM*1155172*75***23::1*Y*A*Y*A*C******P~DTP*431*D8*20030815~HI*BK:9895*BF:78609*BF:7872*BF:7295~NM1*DN*1*TRACY*WALLACE*LEE***24*E02920~REF*1B*50594~NM1*82*1*TRACY*WALLACE*LEE***24*50594~PRV*PE*ZZ*282N00000X~REF*1G*E02920~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99283*75*UN*1*23**1:2:3:4**Y******0~DTP*472*RD8*20030815-20030815~HL*11*1*22*0~SBR*P*18*ASB4305410001*AR BLUE CROSS/BLUE SHIELD*****MB~PAT*~NM1*IL*1*WATSON*KEITH****MI*ASB4305410001~NM1*PR*2*AR BLUE CROSS/BLUE SHIELD*****PI*00520~N3*P O BOX 2181~N4*LITTLE ROCK*AR*722030000~CLM*1155162*75***23::1*Y*A*Y*A*C******P~DTP*431*D8*20030816~HI*BK:2554~NM1*DN*1*TRACY*WALLACE*LEE***24*E02920~REF*1B*50594~NM1*82*1*TRACY*WALLACE*LEE***24*50594~PRV*PE*ZZ*282N00000X~REF*1G*E02920~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99283*75*UN*1*23**1**Y******0~DTP*472*RD8*20030816-20030816~SE*240*00001~GE*1*20030923~IEA*1*000000001~

  29. Questions ?

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