Example: Inpatient Hospital Stay

Example: Inpatient Hospital Stay X12 Admin Wed, 05/13/2026 - 11:17 BUSINESS SCENARIO: Patient is an adult male admitted for an inpatient hospital stay that includes a Device Identifier (DI) for an implantable device. Subscriber is the Patient. The Payer is Commercial. Example: SUBMITTER: SUBMITTER NAME: PROVIDER MEDICAL GROUP SUBMITTER ID: N305 SUBMITTER CONTACT NAME: NINA SUBMITTER CONTACT NUMBER: 6155551212 ext. 911 RECEIVER: RECEIVER NAME: COMMERCIAL RECEIVER RECEIVER ID: 05440 BILLING PROVIDER: BILLING PROVIDER TAXONOMY: 203BA0200N BILLING PROVIDER NAME: PROVIDER MEDICAL GROUP BILLING PROVIDER NPI: 2366554859 BILLING PROVIDER ADDRESS: 123 MAIN STREET, KANSAS CITY, MO, 64105-1909 BILLING PROVIDER TIN: 756473826 SUBSCRIBER: SUBSCRIBER NAME: JOHN JONES SUBSCRIBER ID: 111222345ACI SUBSCRIBER ADDRESS: 123 RAINBOW ROAD, KANSAS CITY, MO, 64105 SUBSCRIBER DOB: 03/03/1954 SUBSCRIBER SEX: M DESTINATION PAYER: PAYER NAME: COMMERCIAL PAYER SECONDARY IDENTIFICATION: 05440 PATIENT: Same as Primary Subscriber CLAIM INFORMATION: ORIGINAL CLAIM CREATION DATE: 01/12/2025 PROVIDER ASSIGNED CLAIM IDENTIFIER: 153829140764352987432 TOTAL CHARGES: $3900 PLACE OF SERVICE CODE: 11 CLAIM FREQUENCY CODE: 1 TIME OF DISCHARGE: 4:00PM STATEMENT PERIOD DATE: 01/12/2025 – 01/22/2025 DATE OF ADMISSION: 01/12/2025 ADMISSION TYPE CODE: 3 (elective) PATIENT STATUS: 01 (discharged to home) DEVICE IDENTIFIER: 00880304454934 PRINCIPAL DIAGNOSIS CODE: M16.11 ADMITTING DIAGNOSIS CODE: M16.11 OCCURRENCE CODE AND DATE: 42, 01/12/2025 (Date of Discharge) VALUE CODE AND AMOUNT: 80, 10 (number of covered days) ATTENDING PROVIDER: ATTENDING PROVIDER NAME: JACOB E. TOWNSEND ATTENDING PROVIDER NPI: 5678912345 SERVICE LINE NUMBER: SERVICE LINE 1 REVENUE CODE: 0120 LINE ITEM CHARGE AMOUNT: $200 UNIT OR BASIS FOR MEASURMENT CODE: DA SERVICE UNIT COUNT: 9 SERVICE LINE 2 REVENUE CODE: 0360 LINE ITEM CHARGE AMOUNT: $1700 UNIT OR BASIS FOR MEASURMENT CODE: UN SERVICE UNIT COUNT: 1 SERVICE LINE 3 REVENUE CODE: 0370 LINE ITEM CHARGE AMOUNT: $400 UNIT OR BASIS FOR MEASURMENT CODE: UN SERVICE UNIT COUNT: 1 Transmission Explanation HEADER ST8370001008060X324~ ST TRANSACTION SET HEADER BHT00190012345202501121549CH~ BHT BEGINNING OF HIERARCHICAL TRANSACTION 1000A SUBMITTER NAME NM1412PROVIDER MEDICAL GROUP**46N305~ NM1 SUBMITTER NAME PERICNINATE6155551212EX911~ PER SUBMITTER EDI CONTACT INFORMATION 1000B RECEIVER NAME NM1402COMMERCIAL RECEIVER4605440~ NM1 RECEIVER NAME 2000A BILLING PROVIDER HL1201~ HL BILLING PROVIDER HIERARCHICAL LEVEL PRVBIPXC203BA0200N~ PRV BILLING PROVIDER SPECIALTY INFORMATION 2010AA BILLING PROVIDER NAME NM1852PROVIDER MEDICAL GROUP**XX2366554859~ NM1 BILLING PROVIDER NAME N3123 Main Street~ N3 BILLING PROVIDER ADDRESS N4KANSAS CITYMO641051909~ N4 BILLING PROVIDER LOCATION REFEI756473826~ REF BILLING PROVIDER TAX IDENTIFICATION 2000B SUBSCRIBER HL LOOP HL21220~ HL SUBSCRIBER HIERARCHICAL LEVEL SBRP18**CI~ SBR SUBSCRIBER INFORMATION 2010BA SUBSCRIBER NAME LOOP NM1IL1JONESJOHNMI111222345ACI~ NM1 SUBSCRIBER NAME N3123 RAINBOW ROAD~ N3 SUBSCRIBER ADDRESS N4KANSAS CITYMO64105~ N4 SUBSCRIBER CITY, STATE, ZIP DMGD819540303~ DMG SUBSCRIBER DEMOGRAPHIC INFORMATION DMHM248152002~ DMH SUBSCRIBER EXTENDED DEMOGRAPHIC INFORMATION 2010BB PAYER NAME LOOP NM1PR2COMMERCIAL~ NM1 PAYER NAME REF2U05440~ REF PAYER SECONDARY IDENTIFICATION 2300 CLAIM INFORMATION CLM153829140764352987432390011:A:1YAYY~ CLM CLAIM LEVEL INFORMATION DTP523D820250112~ DTP ORIGINAL CLAIM CREATION DATE DTP096TM0400~ DTP DISCHARGE TIME DTP435DT20250112~ DTP ADMISSION DATE/HOUR OR START OF CARE DATE DTP434RD820250112–20250122~ DTP STATEMENT DATES CL1301~ CL1 INSTITUTIONAL CLAIM CODE CR8Z100880304454934~ CR8 HIGH RISK IMPLANTED OR EXPLANTED DEVICE HIABK:M1611~ HI PRINCIPAL DIAGNOSIS HIABJ:M1611~ HI ADMITTING DIAGNOSIS HIBH:42:20250112~ HI OCCURRENCE INFORMATION HIBE:80:::10~ HI VALUE INFORMATION 2310A ATTENDING PROVIDER NAME LOOP NM1711TOWNSENDJACOBEXX5678912345~ NM1 ATTENDING PROVIDER NAME 2400 SERVICE LINE NUMBER LX1~ LX SERVICE LINE NUMBER SV20120200*DA*9~ SV2 INSTITUTIONAL SERVICE LINE LX*2~ LX SERVICE LINE NUMBER SV2*3601700UN1~ SV2 INSTITUTIONAL SERVICE LINE LX3~ LX SERVICE LINE NUMBER SV2370**400UN1~ SV2 INSTITUTIONAL SERVICE LINE SE39*0001~ SE TRANSACTION SET TRAILER