/// <summary>
/// Build institutional claim.
/// Original from http://www.x12.org/examples/005010X223/institutional/837-institutional-claim/
/// The patient is a different person than the subscriber. The payer is a commercial health insurance company.
/// Scenario:
/// PRIMARY PAYER SUBSCRIBER: John T Doe
/// SUBSCRIBER ADDRESS: 125 City Avenue, Centerville, PA 17111
/// SEX: M
/// DOB: 11/11/1926
/// MEDICARE INSURANCE ID#: 030005074A
/// PAYER ID #: 00435
/// PATIENT: Same as Primary Subscriber
/// DESTINATION PAYER: Medicare B
/// SUBMITTER: Jones Hospital
/// EDI#: 12345
/// RECEIVER: Medicare
/// EDI#: 00120
/// BILLING PROVIDER: Jones Hospital
/// NPI: 9876540809
/// TIN: 567891234
/// MEDICARE PROVIDER: #330127
/// ADDRESS: 225 Main Street Barkley Building, Centerville, PA 17111
/// ATTENDING PHYSICIAN: John J Jones
/// UPIN #: B99937
/// PATIENT ACCOUNT NUMBER: 756048Q
/// DATE OF ADMISSION: 09/11/96
/// STATEMENT PERIOD DATE: 09/11/96 - 09/11/96
/// PLACE OF SERVICE: Inpatient Hospital
/// Occurrence Codes and Dates:
/// A1 11/11/26
/// A2 11/01/91
/// B1 11/11/26
/// B2 01/01/87
/// Condition Codes: 09
/// Value Codes: A2 $15.31
/// PRINCIPAL DIAGNOSIS CODE: 366.9
/// SECONDARY DIAGNOSIS CODES:
/// 401.9
/// 794.31
/// NUMBER OF COVERED DAYS: 1
/// SERVICES:
/// INSTITUTIONAL SERVICES RENDERED:
/// REVENUE CODE: 0305 HCPCS Procedure Code: 85025 Unit: 1 Price $13.39
/// REVENUE CODE: 0730 HCPCS Procedure Code: 93005 Unit: 1 Price: $76.54
/// TOTAL CHARGES: $89.93
/// SECONDARY PAYER SUBSCRIBER: Jane S Doe(wife)
/// SUBSCRIBER ADDRESS: 125 City Avenue, Centerville, PA 17111
/// SEX: F
/// DOB: 12/11/1927
/// STATE TEACHERS ID#: 222004433
/// PAYER ID #: 1135
/// </summary>
static TS837I BuildInstitutionalClaim(string controlNumber)
{
var result = new TS837I();
// ST TRANSACTION SET HEADER
result.ST = new ST();
result.ST.TransactionSetIdentifierCode_01 = "837";
result.ST.TransactionSetControlNumber_02 = controlNumber.PadLeft(9, '0');
result.ST.ImplementationConventionPreference_03 = "005010X223A2";
// BHT BEGINNING OF HIERARCHICAL TRANSACTION
result.BHT_BeginningofHierarchicalTransaction = new BHT_BeginningofHierarchicalTransaction_7();
result.BHT_BeginningofHierarchicalTransaction.HierarchicalStructureCode_01 = "0019";
result.BHT_BeginningofHierarchicalTransaction.TransactionSetPurposeCode_02 = "00";
result.BHT_BeginningofHierarchicalTransaction.SubmitterTransactionIdentifier_03 = "0123";
result.BHT_BeginningofHierarchicalTransaction.TransactionSetCreationDate_04 = "19960918";
result.BHT_BeginningofHierarchicalTransaction.TransactionSetCreationTime_05 = "0932";
result.BHT_BeginningofHierarchicalTransaction.TransactionTypeCode_06 = "CH";
// Occurrence of NM1 Loops in any order
result.AllNM1 = new All_NM1_837I_6();
// Begin 1000A Loop SUBMITTER NAME
result.AllNM1.Loop1000A = new Loop_1000A_837I();
// NM1 SUBMITTER NAME
result.AllNM1.Loop1000A.NM1_SubmitterName = new NM1_InformationReceiverName_2();
result.AllNM1.Loop1000A.NM1_SubmitterName.EntityIdentifierCode_01 = "41";
result.AllNM1.Loop1000A.NM1_SubmitterName.EntityTypeQualifier_02 = "2";
result.AllNM1.Loop1000A.NM1_SubmitterName.ResponseContactLastorOrganizationName_03 = "JONES HOSPITAL";
result.AllNM1.Loop1000A.NM1_SubmitterName.IdentificationCodeQualifier_08 = "46";
result.AllNM1.Loop1000A.NM1_SubmitterName.ResponseContactIdentifier_09 = "12345";
// Repeating PER Patient information
result.AllNM1.Loop1000A.PER_SubmitterEDIContactInformation = new List <PER_AdditionalPatientInformationContactInformation>();
// PER SUBMITTER EDI CONTACT INFORMATION
var per1 = new PER_AdditionalPatientInformationContactInformation();
per1.ContactFunctionCode_01 = "IC";
per1.ResponseContactName_02 = "JANE DOE";
per1.CommunicationNumberQualifier_03 = "TE";
per1.ResponseContactCommunicationNumber_04 = "9005555555";
result.AllNM1.Loop1000A.PER_SubmitterEDIContactInformation.Add(per1);
// End 1000A Loop
// Begin 1000B Loop RECEIVER NAME
result.AllNM1.Loop1000B = new Loop_1000B_837I();
// NM1 RECEIVER NAME
result.AllNM1.Loop1000B.NM1_ReceiverName = new NM1_ReceiverName();
result.AllNM1.Loop1000B.NM1_ReceiverName.EntityIdentifierCode_01 = "40";
result.AllNM1.Loop1000B.NM1_ReceiverName.EntityTypeQualifier_02 = "2";
result.AllNM1.Loop1000B.NM1_ReceiverName.ResponseContactLastorOrganizationName_03 = "MEDICARE";
result.AllNM1.Loop1000B.NM1_ReceiverName.IdentificationCodeQualifier_08 = "46";
result.AllNM1.Loop1000B.NM1_ReceiverName.ResponseContactIdentifier_09 = "00120";
// End 1000B Loop
// Repeating 2000A Loops
result.Loop2000A = new List <Loop_2000A_837I>();
// Begin 2000A Loop BILLING PROVIDER
var loop2000A = new Loop_2000A_837I();
// HL BILLING PROVIDER HIERARCHICAL LEVEL
loop2000A.HL_BillingProviderHierarchicalLevel = new HL_BillingProviderHierarchicalLevel();
loop2000A.HL_BillingProviderHierarchicalLevel.HierarchicalIDNumber_01 = "1";
loop2000A.HL_BillingProviderHierarchicalLevel.HierarchicalLevelCode_03 = "20";
loop2000A.HL_BillingProviderHierarchicalLevel.HierarchicalChildCode_04 = "1";
// PRV BILLING PROVIDER SPECIALTY
loop2000A.PRV_BillingProviderSpecialtyInformation = new PRV_BillingProviderSpecialtyInformation();
loop2000A.PRV_BillingProviderSpecialtyInformation.ProviderCode_01 = "BI";
loop2000A.PRV_BillingProviderSpecialtyInformation.ReferenceIdentificationQualifier_02 = "PXC";
loop2000A.PRV_BillingProviderSpecialtyInformation.ProviderTaxonomyCode_03 = "203BA0200N";
// Occurrence of NM1 Loops in any order
loop2000A.AllNM1 = new All_NM1_837I();
// Begin 2010AA Loop BILLING PROVIDER NAME
loop2000A.AllNM1.Loop2010AA = new Loop_2010AA_837I();
// NM1 BILLING PROVIDER NAME INCLUDING NATIONAL PROVIDER ID
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName = new NM1_BillingProviderName_2();
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.EntityIdentifierCode_01 = "85";
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.EntityTypeQualifier_02 = "2";
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.ResponseContactLastorOrganizationName_03 = "JONES HOSPITAL";
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.IdentificationCodeQualifier_08 = "XX";
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.ResponseContactIdentifier_09 = "9876540809";
// N3 BILLING PROVIDER ADDRESS
loop2000A.AllNM1.Loop2010AA.N3_BillingProviderAddress = new N3_AdditionalPatientInformationContactAddress();
loop2000A.AllNM1.Loop2010AA.N3_BillingProviderAddress.ResponseContactAddressLine_01 = "225 MAIN STREET BARKLEY BUILDING";
// N4 BILLING PROVIDER LOCATION
loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode = new N4_AdditionalPatientInformationContactCity();
loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode.AdditionalPatientInformationContactCityName_01 = "CENTERVILLE";
loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode.AdditionalPatientInformationContactStateCode_02 = "PA";
loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode.AdditionalPatientInformationContactPostalZoneorZIPCode_03 = "17111";
// REF BILLING PROVIDER TAX IDENTIFICATION NUMBER
loop2000A.AllNM1.Loop2010AA.REF_BillingProviderTaxIdentification = new REF_BillingProviderTaxIdentification_2();
loop2000A.AllNM1.Loop2010AA.REF_BillingProviderTaxIdentification.ReferenceIdentificationQualifier_01 = "EI";
loop2000A.AllNM1.Loop2010AA.REF_BillingProviderTaxIdentification.MemberGrouporPolicyNumber_02 = "567891234";
// Repeating PER billing provider contact information
loop2000A.AllNM1.Loop2010AA.PER_BillingProviderContactInformation = new List <PER_AdditionalPatientInformationContactInformation>();
// PER BILLING PROVIDER CONTACT INFORMATION
var per2 = new PER_AdditionalPatientInformationContactInformation();
per2.ContactFunctionCode_01 = "IC";
per2.ResponseContactName_02 = "CONNIE";
per2.CommunicationNumberQualifier_03 = "TE";
per2.ResponseContactCommunicationNumber_04 = "3055551234";
loop2000A.AllNM1.Loop2010AA.PER_BillingProviderContactInformation.Add(per2);
// End 2010AA Loop
// Repeating 2000B Loops
loop2000A.Loop2000B = new List <Loop_2000B_837I>();
// Begin 2000B Loop SUBSCRIBER HL LOOP
var loop2000B = new Loop_2000B_837I();
// HL SUBSCRIBER HIERARCHICAL LEVEL
loop2000B.HL_SubscriberHierarchicalLevel = new HL_SubscriberHierarchicalLevel();
loop2000B.HL_SubscriberHierarchicalLevel.HierarchicalIDNumber_01 = "2";
loop2000B.HL_SubscriberHierarchicalLevel.HierarchicalParentIDNumber_02 = "1";
loop2000B.HL_SubscriberHierarchicalLevel.HierarchicalLevelCode_03 = "22";
loop2000B.HL_SubscriberHierarchicalLevel.HierarchicalChildCode_04 = "0";
// SBR SUBSCRIBER INFORMATION
loop2000B.SBR_SubscriberInformation = new SBR_SubscriberInformation();
loop2000B.SBR_SubscriberInformation.PayerResponsibilitySequenceNumberCode_01 = "P";
loop2000B.SBR_SubscriberInformation.IndividualRelationshipCode_02 = "18";
loop2000B.SBR_SubscriberInformation.ClaimFilingIndicatorCode_09 = "MB";
// Occurrence of NM1 Loops in any order
loop2000B.AllNM1 = new All_NM1_837I_2();
// Begin 2010BA Loop SUBSCRIBER NAME LOOP
loop2000B.AllNM1.Loop2010BA = new Loop_2010BA_837I();
// NM1 SUBSCRIBER NAME
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName = new NM1_InsuredName();
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.EntityIdentifierCode_01 = "IL";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.EntityTypeQualifier_02 = "1";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactLastorOrganizationName_03 = "DOE";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactFirstName_04 = "JOHN";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactMiddleName_05 = "T";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.IdentificationCodeQualifier_08 = "MI";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactIdentifier_09 = "030005074A";
// N3 SUBSCRIBER ADDRESS
loop2000B.AllNM1.Loop2010BA.N3_SubscriberAddress = new N3_AdditionalPatientInformationContactAddress();
loop2000B.AllNM1.Loop2010BA.N3_SubscriberAddress.ResponseContactAddressLine_01 = "125 CITY AVENUE";
// N4 SUBSCRIBER LOCATION
loop2000B.AllNM1.Loop2010BA.N4_SubscriberCity_State_ZIPCode = new N4_AdditionalPatientInformationContactCity();
loop2000B.AllNM1.Loop2010BA.N4_SubscriberCity_State_ZIPCode.AdditionalPatientInformationContactCityName_01 = "CENTERVILLE";
loop2000B.AllNM1.Loop2010BA.N4_SubscriberCity_State_ZIPCode.AdditionalPatientInformationContactStateCode_02 = "PA";
loop2000B.AllNM1.Loop2010BA.N4_SubscriberCity_State_ZIPCode.AdditionalPatientInformationContactPostalZoneorZIPCode_03 = "17111";
// DMG SUBSCRIBER DEMOGRAPHIC INFORMATION
loop2000B.AllNM1.Loop2010BA.DMG_SubscriberDemographicInformation = new DMG_DependentDemographicInformation();
loop2000B.AllNM1.Loop2010BA.DMG_SubscriberDemographicInformation.DateTimePeriodFormatQualifier_01 = "D8";
loop2000B.AllNM1.Loop2010BA.DMG_SubscriberDemographicInformation.DependentBirthDate_02 = "19261111";
loop2000B.AllNM1.Loop2010BA.DMG_SubscriberDemographicInformation.DependentGenderCode_03 = "M";
// End 2010BA Loop
// Begin 2010BB Loop PAYER NAME LOOP
loop2000B.AllNM1.Loop2010BB = new Loop_2010BB_837I();
// NM1 PAYER NAME
loop2000B.AllNM1.Loop2010BB.NM1_PayerName = new NM1_CorrectedPriorityPayerName();
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.EntityIdentifierCode_01 = "PR";
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.EntityTypeQualifier_02 = "2";
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.ResponseContactLastorOrganizationName_03 = "MEDICARE B";
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.IdentificationCodeQualifier_08 = "PI";
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.ResponseContactIdentifier_09 = "00435";
// Occurrence of REF Segments in any order
loop2000B.AllNM1.Loop2010BB.AllREF = new All_REF_837I_3();
// REF BILLING PROVIDER SECONDARY IDENTIFICATION
loop2000B.AllNM1.Loop2010BB.AllREF.REF_BillingProviderSecondaryIdentification = new REF_BillingProviderSecondaryIdentification();
loop2000B.AllNM1.Loop2010BB.AllREF.REF_BillingProviderSecondaryIdentification.ReferenceIdentificationQualifier_01 = "G2";
loop2000B.AllNM1.Loop2010BB.AllREF.REF_BillingProviderSecondaryIdentification.MemberGrouporPolicyNumber_02 = "330127";
// End 2010BB Loop
// Repeating 2300 Loops
loop2000B.Loop2300 = new List <Loop_2300_837I_2>();
// Begin 2300 Loop CLAIM INFORMATION
var loop2300 = new Loop_2300_837I_2();
// CLM CLAIM LEVEL INFORMATION
loop2300.CLM_Claiminformation = new CLM_ClaimInformation();
loop2300.CLM_Claiminformation.PatientControlNumber_01 = "756048Q";
loop2300.CLM_Claiminformation.TotalClaimChargeAmount_02 = "89.93";
loop2300.CLM_Claiminformation.NonInstitutionalClaimTypeCode_04 = "14:A:1";
loop2300.CLM_Claiminformation.HealthCareServiceLocationInformation_05 = new C023_HealthCareServiceLocationInformation();
loop2300.CLM_Claiminformation.HealthCareServiceLocationInformation_05.FacilityTypeCode_01 = "A";
loop2300.CLM_Claiminformation.ProviderorSupplierSignatureIndicator_06 = "Y";
loop2300.CLM_Claiminformation.AssignmentorPlanParticipationCode_07 = "Y";
// Occurrence of DTP Segments in any order
loop2300.AllDTP = new All_DTP_837I();
// DTP STATEMENT DATES
loop2300.AllDTP.DTP_StatementDates = new DTP_StatementDates();
loop2300.AllDTP.DTP_StatementDates.DateTimeQualifier_01 = "434";
loop2300.AllDTP.DTP_StatementDates.DateTimePeriodFormatQualifier_02 = "RD8";
loop2300.AllDTP.DTP_StatementDates.AccidentDate_03 = "19960911";
// CL1 INSTITUTIONAL CLAIM CODE
loop2300.CL1_InstitutionalClaimCode = new CL1_InstitutionalClaimCode();
loop2300.CL1_InstitutionalClaimCode.AdmissionTypeCode_01 = "3";
loop2300.CL1_InstitutionalClaimCode.PatientStatusCode_03 = "01";
// Occurrence of HI Segments in any order
loop2300.AllHI = new All_HI_837I();
// HI PRINCIPAL DIAGNOSIS CODES
loop2300.AllHI.HI_PrincipalDiagnosis = new HI_PrincipalDiagnosis();
loop2300.AllHI.HI_PrincipalDiagnosis.HealthCareCodeInformation_01 = new C022_HealthCareCodeInformation();
loop2300.AllHI.HI_PrincipalDiagnosis.HealthCareCodeInformation_01.CodeListQualifierCode_01 = "BK";
loop2300.AllHI.HI_PrincipalDiagnosis.HealthCareCodeInformation_01.IndustryCode_02 = "3669";
// Repeatable HI Other Diagnostics
loop2300.AllHI.HI_OtherDiagnosisInformation = new List <HI_OtherDiagnosisInformation>();
// HI OTHER DIAGNOSIS INFORMATION
var hi1 = new HI_OtherDiagnosisInformation();
hi1.HealthCareCodeInformation_01 = new C022_HealthCareCodeInformation();
hi1.HealthCareCodeInformation_01.CodeListQualifierCode_01 = "BF";
hi1.HealthCareCodeInformation_01.IndustryCode_02 = "4019";
hi1.HealthCareCodeInformation_02 = new C022_HealthCareCodeInformation();
hi1.HealthCareCodeInformation_02.CodeListQualifierCode_01 = "BF";
hi1.HealthCareCodeInformation_02.IndustryCode_02 = "79431";
loop2300.AllHI.HI_OtherDiagnosisInformation.Add(hi1);
// Repeatable HI Occurrence Information
loop2300.AllHI.HI_OccurrenceInformation = new List <HI_OccurrenceInformation>();
// HI OCCURRENCE INFORMATION
var hi3 = new HI_OccurrenceInformation();
hi3.HealthCareCodeInformation_01 = new C022_HealthCareCodeInformation();
hi3.HealthCareCodeInformation_01.CodeListQualifierCode_01 = "BH";
hi3.HealthCareCodeInformation_01.IndustryCode_02 = "A1";
hi3.HealthCareCodeInformation_01.DateTimePeriodFormatQualifier_03 = "D8";
hi3.HealthCareCodeInformation_01.DateTimePeriod_04 = "19261111";
hi3.HealthCareCodeInformation_02 = new C022_HealthCareCodeInformation();
hi3.HealthCareCodeInformation_02.CodeListQualifierCode_01 = "BH";
hi3.HealthCareCodeInformation_02.IndustryCode_02 = "A2";
hi3.HealthCareCodeInformation_02.DateTimePeriodFormatQualifier_03 = "D8";
hi3.HealthCareCodeInformation_02.DateTimePeriod_04 = "19911101";
hi3.HealthCareCodeInformation_03 = new C022_HealthCareCodeInformation();
hi3.HealthCareCodeInformation_03 = new C022_HealthCareCodeInformation();
hi3.HealthCareCodeInformation_03.CodeListQualifierCode_01 = "BH";
hi3.HealthCareCodeInformation_03.IndustryCode_02 = "B1";
hi3.HealthCareCodeInformation_03.DateTimePeriodFormatQualifier_03 = "D8";
hi3.HealthCareCodeInformation_03.DateTimePeriod_04 = "19261111";
hi3.HealthCareCodeInformation_04 = new C022_HealthCareCodeInformation();
hi3.HealthCareCodeInformation_04.CodeListQualifierCode_01 = "BH";
hi3.HealthCareCodeInformation_04.IndustryCode_02 = "B2";
hi3.HealthCareCodeInformation_04.DateTimePeriodFormatQualifier_03 = "D8";
hi3.HealthCareCodeInformation_04.DateTimePeriod_04 = "19870101";
loop2300.AllHI.HI_OccurrenceInformation.Add(hi3);
// Repeatable HI Value Information
loop2300.AllHI.HI_ValueInformation = new List <HI_ValueInformation>();
// HI VALUE INFORMATION
var hi7 = new HI_ValueInformation();
hi7.HealthCareCodeInformation_01 = new C022_HealthCareCodeInformation();
hi7.HealthCareCodeInformation_01.CodeListQualifierCode_01 = "BE";
hi7.HealthCareCodeInformation_01.IndustryCode_02 = "A2";
hi7.HealthCareCodeInformation_01.MonetaryAmount_05 = "15.31";
loop2300.AllHI.HI_ValueInformation.Add(hi7);
// Repeatable HI Condition Information
loop2300.AllHI.HI_ConditionInformation = new List <HI_ConditionInformation>();
// HI CONDITION INFORMATION
var hi8 = new HI_ConditionInformation();
hi8.HealthCareCodeInformation_01 = new C022_HealthCareCodeInformation();
hi8.HealthCareCodeInformation_01.CodeListQualifierCode_01 = "BG";
hi8.HealthCareCodeInformation_01.IndustryCode_02 = "09";
loop2300.AllHI.HI_ConditionInformation.Add(hi8);
// Occurrence of NM1 Loops in any order
loop2300.AllNM1 = new All_NM1_837I_3();
// Begin 2310A Loop ATTENDING PROVIDER NAME
loop2300.AllNM1.Loop2310A = new Loop_2310A_837I();
// NM1 ATTENDING PROVIDER
loop2300.AllNM1.Loop2310A.NM1_AttendingProviderName = new NM1_AttendingProviderName();
loop2300.AllNM1.Loop2310A.NM1_AttendingProviderName.EntityIdentifierCode_01 = "71";
loop2300.AllNM1.Loop2310A.NM1_AttendingProviderName.EntityTypeQualifier_02 = "1";
loop2300.AllNM1.Loop2310A.NM1_AttendingProviderName.ResponseContactLastorOrganizationName_03 = "JONES";
loop2300.AllNM1.Loop2310A.NM1_AttendingProviderName.ResponseContactFirstName_04 = "JOHN";
loop2300.AllNM1.Loop2310A.NM1_AttendingProviderName.ResponseContactMiddleName_05 = "J";
// Repeating REF Secondary Identification
loop2300.AllNM1.Loop2310A.REF_AttendingProviderSecondaryIdentification = new List <REF_AssistantSurgeonSecondaryIdentification>();
// REF ATTENDING PROVIDER SECONDARY IDENTIFICATION
var ref1 = new REF_AssistantSurgeonSecondaryIdentification();
ref1.ReferenceIdentificationQualifier_01 = "1G";
ref1.MemberGrouporPolicyNumber_02 = "B99937";
loop2300.AllNM1.Loop2310A.REF_AttendingProviderSecondaryIdentification.Add(ref1);
// End 2310A Loop
// Repeating 2320 Loops
loop2300.Loop2320 = new List <Loop_2320_837I>();
// Begin 2320 Loop OTHER SUBSCRIBER INFORMATION
var loop2320 = new Loop_2320_837I();
// SBR OTHER SUBSCRIBER INFORMATION
loop2320.SBR_OtherSubscriberInformation = new SBR_OtherSubscriberInformation();
loop2320.SBR_OtherSubscriberInformation.PayerResponsibilitySequenceNumberCode_01 = "S";
loop2320.SBR_OtherSubscriberInformation.IndividualRelationshipCode_02 = "01";
loop2320.SBR_OtherSubscriberInformation.InsuredGrouporPolicyNumber_03 = "351630";
loop2320.SBR_OtherSubscriberInformation.OtherInsuredGroupName_04 = "STATE TEACHERS";
loop2320.SBR_OtherSubscriberInformation.ClaimFilingIndicatorCode_09 = "CI";
// OI OTHER INSURANCE COVERAGE INFORMATION
loop2320.OI_OtherInsuranceCoverageInformation = new OI_OtherInsuranceCoverageInformation();
loop2320.OI_OtherInsuranceCoverageInformation.BenefitsAssignmentCertificationIndicator_03 = "Y";
loop2320.OI_OtherInsuranceCoverageInformation.ReleaseofInformationCode_06 = "Y";
// Occurrence of NM1 Loops in any order
loop2320.AllNM1 = new All_NM1_837I_4();
// Begin 2330A Loop OTHER SUBSCRIBER NAME
loop2320.AllNM1.Loop2330A = new Loop_2330A_837I();
// NM1 OTHER SUBSCRIBER NAME
loop2320.AllNM1.Loop2330A.NM1_OtherSubscriberName = new NM1_InsuredName();
loop2320.AllNM1.Loop2330A.NM1_OtherSubscriberName.EntityIdentifierCode_01 = "IL";
loop2320.AllNM1.Loop2330A.NM1_OtherSubscriberName.EntityTypeQualifier_02 = "1";
loop2320.AllNM1.Loop2330A.NM1_OtherSubscriberName.ResponseContactLastorOrganizationName_03 = "DOE";
loop2320.AllNM1.Loop2330A.NM1_OtherSubscriberName.ResponseContactFirstName_04 = "JANE";
loop2320.AllNM1.Loop2330A.NM1_OtherSubscriberName.ResponseContactMiddleName_05 = "S";
loop2320.AllNM1.Loop2330A.NM1_OtherSubscriberName.IdentificationCodeQualifier_08 = "MI";
loop2320.AllNM1.Loop2330A.NM1_OtherSubscriberName.ResponseContactIdentifier_09 = "222004433";
// N3 OTHER SUBSCRIBER ADDRESS
loop2320.AllNM1.Loop2330A.N3_OtherSubscriberAddress = new N3_AdditionalPatientInformationContactAddress();
loop2320.AllNM1.Loop2330A.N3_OtherSubscriberAddress.ResponseContactAddressLine_01 = "125 CITY AVENUE";
// N4 OTHER SUBSCRIBER CITY, STATE, ZIP CODE
loop2320.AllNM1.Loop2330A.N4_OtherSubscriberCity_State_ZIPCode = new N4_AdditionalPatientInformationContactCity();
loop2320.AllNM1.Loop2330A.N4_OtherSubscriberCity_State_ZIPCode.AdditionalPatientInformationContactCityName_01 = "CENTERVILLE";
loop2320.AllNM1.Loop2330A.N4_OtherSubscriberCity_State_ZIPCode.AdditionalPatientInformationContactStateCode_02 = "PA";
loop2320.AllNM1.Loop2330A.N4_OtherSubscriberCity_State_ZIPCode.AdditionalPatientInformationContactPostalZoneorZIPCode_03 = "17111";
// End 2330A Loop
// Begin 2330B Loop OTHER PAYER NAME
loop2320.AllNM1.Loop2330B = new Loop_2330B_837I();
// NM1 OTHER PAYER NAME
loop2320.AllNM1.Loop2330B.NM1_OtherPayerName = new NM1_CorrectedPriorityPayerName();
loop2320.AllNM1.Loop2330B.NM1_OtherPayerName.EntityIdentifierCode_01 = "PR";
loop2320.AllNM1.Loop2330B.NM1_OtherPayerName.EntityTypeQualifier_02 = "2";
loop2320.AllNM1.Loop2330B.NM1_OtherPayerName.ResponseContactLastorOrganizationName_03 = "STATE TEACHERS";
loop2320.AllNM1.Loop2330B.NM1_OtherPayerName.IdentificationCodeQualifier_08 = "PI";
loop2320.AllNM1.Loop2330B.NM1_OtherPayerName.ResponseContactIdentifier_09 = "1135";
// End 2330B Loop
// End 2320 Loop
loop2300.Loop2320.Add(loop2320);
// Repeating 2400 Loops
loop2300.Loop2400 = new List <Loop_2400_837I>();
// Begin 2400 Loop 1 SERVICE LINE
var loop24001 = new Loop_2400_837I();
// LX SERVICE LINE COUNTER
loop24001.LX_ServiceLineNumber = new LX_HeaderNumber();
loop24001.LX_ServiceLineNumber.AssignedNumber_01 = "1";
// SV2 INSTITUTIONAL SERVICE
loop24001.SV2_InstitutionalServiceLine = new SV2_InstitutionalServiceLine();
loop24001.SV2_InstitutionalServiceLine.ServiceLineRevenueCode_01 = "0305";
loop24001.SV2_InstitutionalServiceLine.CompositeMedicalProcedureIdentifier_02 = new C003_CompositeMedicalProcedureIdentifier();
loop24001.SV2_InstitutionalServiceLine.CompositeMedicalProcedureIdentifier_02.ProductorServiceIDQualifier_01 = "HC";
loop24001.SV2_InstitutionalServiceLine.CompositeMedicalProcedureIdentifier_02.ProcedureCode_02 = "85025";
loop24001.SV2_InstitutionalServiceLine.LineItemChargeAmount_03 = "13.39";
loop24001.SV2_InstitutionalServiceLine.UnitorBasisforMeasurementCode_04 = "UN";
loop24001.SV2_InstitutionalServiceLine.ServiceUnitCount_05 = "1";
// DTP DATE - SERVICE DATES
loop24001.DTP_Date_ServiceDate = new DTP_ClaimLevelServiceDate();
loop24001.DTP_Date_ServiceDate.DateTimeQualifier_01 = "472";
loop24001.DTP_Date_ServiceDate.DateTimePeriodFormatQualifier_02 = "D8";
loop24001.DTP_Date_ServiceDate.AccidentDate_03 = "19960911";
// End 2400 Loop 1
loop2300.Loop2400.Add(loop24001);
// Begin 2400 Loop 2 SERVICE LINE
var loop24002 = new Loop_2400_837I();
// LX SERVICE LINE COUNTER
loop24002.LX_ServiceLineNumber = new LX_HeaderNumber();
loop24002.LX_ServiceLineNumber.AssignedNumber_01 = "2";
// SV2 INSTITUTIONAL SERVICE
loop24002.SV2_InstitutionalServiceLine = new SV2_InstitutionalServiceLine();
loop24002.SV2_InstitutionalServiceLine.ServiceLineRevenueCode_01 = "0730";
loop24002.SV2_InstitutionalServiceLine.CompositeMedicalProcedureIdentifier_02 = new C003_CompositeMedicalProcedureIdentifier();
loop24002.SV2_InstitutionalServiceLine.CompositeMedicalProcedureIdentifier_02.ProductorServiceIDQualifier_01 = "HC";
loop24002.SV2_InstitutionalServiceLine.CompositeMedicalProcedureIdentifier_02.ProcedureCode_02 = "93005";
loop24002.SV2_InstitutionalServiceLine.LineItemChargeAmount_03 = "76.54";
loop24002.SV2_InstitutionalServiceLine.UnitorBasisforMeasurementCode_04 = "UN";
loop24002.SV2_InstitutionalServiceLine.ServiceUnitCount_05 = "3";
// DTP DATE - SERVICE DATES
loop24002.DTP_Date_ServiceDate = new DTP_ClaimLevelServiceDate();
loop24002.DTP_Date_ServiceDate.DateTimeQualifier_01 = "472";
loop24002.DTP_Date_ServiceDate.DateTimePeriodFormatQualifier_02 = "D8";
loop24002.DTP_Date_ServiceDate.AccidentDate_03 = "19960911";
// End 2400 Loop 2
loop2300.Loop2400.Add(loop24002);
// End 2300 Loop
loop2000B.Loop2300.Add(loop2300);
// End 2000B Loop
loop2000A.Loop2000B.Add(loop2000B);
// End 2000A Loop
result.Loop2000A.Add(loop2000A);
return(result);
}
/// <summary>
/// Build claim.
/// Original from http://www.x12.org/examples/005010X222/commercial-health-insurance/
/// </summary>
public static TS837P BuildClaim(string controlNumber)
{
var result = new TS837P();
// Indicates the start of a claim transaction set and assigns a control number.
result.ST = new ST();
result.ST.TransactionSetIdentifierCode_01 = "837";
result.ST.TransactionSetControlNumber_02 = controlNumber.PadLeft(9, '0');
result.ST.ImplementationConventionPreference_03 = "005010X222A1";
// Indicates the claim was created on October 15, 2006 and submitter is identified with 244579.
result.BHT_BeginningofHierarchicalTransaction = new BHT_BeginningofHierarchicalTransaction_7();
result.BHT_BeginningofHierarchicalTransaction.HierarchicalStructureCode_01 = "0019";
result.BHT_BeginningofHierarchicalTransaction.TransactionSetPurposeCode_02 = "00";
result.BHT_BeginningofHierarchicalTransaction.SubmitterTransactionIdentifier_03 = "244579";
result.BHT_BeginningofHierarchicalTransaction.TransactionSetCreationDate_04 = "20061015";
result.BHT_BeginningofHierarchicalTransaction.TransactionSetCreationTime_05 = "1023";
result.BHT_BeginningofHierarchicalTransaction.TransactionTypeCode_06 = "CH";
// Occurrence of NM1 Loops in any order
result.AllNM1 = new All_NM1_837P_6();
// Begin 1000A Loop SUBMITTER
result.AllNM1.Loop1000A = new Loop_1000A_837P();
// Premier Billing Service with EDI# TGJ23
result.AllNM1.Loop1000A.NM1_SubmitterName = new NM1_InformationReceiverName_2();
result.AllNM1.Loop1000A.NM1_SubmitterName.EntityIdentifierCode_01 = "41";
result.AllNM1.Loop1000A.NM1_SubmitterName.EntityTypeQualifier_02 = "2";
result.AllNM1.Loop1000A.NM1_SubmitterName.ResponseContactLastorOrganizationName_03 = "PREMIER BILLING SERVICE";
result.AllNM1.Loop1000A.NM1_SubmitterName.IdentificationCodeQualifier_08 = "46";
result.AllNM1.Loop1000A.NM1_SubmitterName.ResponseContactIdentifier_09 = "TGJ23";
// Repeating PER
result.AllNM1.Loop1000A.PER_SubmitterEDIContactInformation = new List <PER_AdditionalPatientInformationContactInformation>();
// CONTACT PERSON AND PHONE NUMBER: JERRY, 305-555-2222 ext. 231
var perLoop1000A = new PER_AdditionalPatientInformationContactInformation();
perLoop1000A.ContactFunctionCode_01 = "IC";
perLoop1000A.ResponseContactName_02 = "JERRY";
perLoop1000A.CommunicationNumberQualifier_03 = "TE";
perLoop1000A.ResponseContactCommunicationNumber_04 = "3055552222";
perLoop1000A.CommunicationNumberQualifier_05 = "EX";
perLoop1000A.ResponseContactCommunicationNumber_06 = "231";
result.AllNM1.Loop1000A.PER_SubmitterEDIContactInformation.Add(perLoop1000A);
// End 1000A Loop SUBMITTER
// Begin 1000B Loop RECEIVER
result.AllNM1.Loop1000B = new Loop_1000B_837P();
// Key Insurance Company with EDI #:66783JJT
result.AllNM1.Loop1000B.NM1_ReceiverName = new NM1_ReceiverName();
result.AllNM1.Loop1000B.NM1_ReceiverName.EntityIdentifierCode_01 = "40";
result.AllNM1.Loop1000B.NM1_ReceiverName.EntityTypeQualifier_02 = "2";
result.AllNM1.Loop1000B.NM1_ReceiverName.ResponseContactLastorOrganizationName_03 = "KEY INSURANCE COMPANY";
result.AllNM1.Loop1000B.NM1_ReceiverName.IdentificationCodeQualifier_08 = "46";
result.AllNM1.Loop1000B.NM1_ReceiverName.ResponseContactIdentifier_09 = "66783JJT";
// End 1000B Loop RECEIVER
// Repeating 2000A Loops
result.Loop2000A = new List <Loop_2000A_837P>();
// Begin 2000A Loop BILLING PROVIDER Hierarchy
var loop2000A = new Loop_2000A_837P();
// Hierarchical Number 1
loop2000A.HL_BillingProviderHierarchicalLevel = new HL_BillingProviderHierarchicalLevel();
loop2000A.HL_BillingProviderHierarchicalLevel.HierarchicalIDNumber_01 = "1";
loop2000A.HL_BillingProviderHierarchicalLevel.HierarchicalLevelCode_03 = "20";
loop2000A.HL_BillingProviderHierarchicalLevel.HierarchicalChildCode_04 = "1";
// Taxonomy Code: 203BF0100Y
loop2000A.PRV_BillingProviderSpecialtyInformation = new PRV_BillingProviderSpecialtyInformation();
loop2000A.PRV_BillingProviderSpecialtyInformation.ProviderCode_01 = "BI";
loop2000A.PRV_BillingProviderSpecialtyInformation.ReferenceIdentificationQualifier_02 = "PXC";
loop2000A.PRV_BillingProviderSpecialtyInformation.ProviderTaxonomyCode_03 = "203BF0100Y";
// Occurrence of NM1 Loops in any order
loop2000A.AllNM1 = new All_NM1_837P();
// Begin 2010AA Loop BILLING PROVIDER
loop2000A.AllNM1.Loop2010AA = new Loop_2010AA_837P();
// Name is BEN KILDARE SERVICE with NPI: 9876543210
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName = new NM1_BillingProviderName();
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.EntityIdentifierCode_01 = "85";
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.EntityTypeQualifier_02 = "2";
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.ResponseContactLastorOrganizationName_03 = "BEN KILDARE SERVICE";
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.IdentificationCodeQualifier_08 = "XX";
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.ResponseContactIdentifier_09 = "9876543210";
// ADDRESS: 234 Seaway St
loop2000A.AllNM1.Loop2010AA.N3_BillingProviderAddress = new N3_AdditionalPatientInformationContactAddress();
loop2000A.AllNM1.Loop2010AA.N3_BillingProviderAddress.ResponseContactAddressLine_01 = "234 SEAWAY ST";
// LOCATION: Miami, FL, 33111
loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode = new N4_AdditionalPatientInformationContactCity();
loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode.AdditionalPatientInformationContactCityName_01 = "MIAMI";
loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode.AdditionalPatientInformationContactStateCode_02 = "FL";
loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode.AdditionalPatientInformationContactPostalZoneorZIPCode_03 = "33111";
// Occurrence of REF Loops in any order
loop2000A.AllNM1.Loop2010AA.AllREF = new All_REF_837P_8();
// TIN: 587654321
loop2000A.AllNM1.Loop2010AA.AllREF.REF_BillingProviderTaxIdentification = new REF_BillingProviderTaxIdentification();
loop2000A.AllNM1.Loop2010AA.AllREF.REF_BillingProviderTaxIdentification.ReferenceIdentificationQualifier_01 = "EI";
loop2000A.AllNM1.Loop2010AA.AllREF.REF_BillingProviderTaxIdentification.MemberGrouporPolicyNumber_02 = "587654321";
// End 2010AA Loop BILLING PROVIDER
// Begin 2010AB Loop PAY-TO PROVIDER
loop2000A.AllNM1.Loop2010AB = new Loop_2010AB_837P();
// PAY-TO PROVIDER Name is Kildare Associates
loop2000A.AllNM1.Loop2010AB.NM1_Pay_AddressName = new NM1_Pay();
loop2000A.AllNM1.Loop2010AB.NM1_Pay_AddressName.EntityIdentifierCode_01 = "87";
loop2000A.AllNM1.Loop2010AB.NM1_Pay_AddressName.EntityTypeQualifier_02 = "2";
loop2000A.AllNM1.Loop2010AB.NM1_Pay_AddressName.ResponseContactLastorOrganizationName_03 = "Kildare Associates";
// PROVIDER ADDRESS: 2345 Ocean Blvd
loop2000A.AllNM1.Loop2010AB.N3_Pay_ToAddress_ADDRESS = new N3_AdditionalPatientInformationContactAddress();
loop2000A.AllNM1.Loop2010AB.N3_Pay_ToAddress_ADDRESS.ResponseContactAddressLine_01 = "2345 OCEAN BLVD";
// PROVIDER LOCATION: Miami, Fl 33111
loop2000A.AllNM1.Loop2010AB.N4_Pay_AddressCity_State_ZIPCode = new N4_AdditionalPatientInformationContactCity();
loop2000A.AllNM1.Loop2010AB.N4_Pay_AddressCity_State_ZIPCode.AdditionalPatientInformationContactCityName_01 = "MIAMI";
loop2000A.AllNM1.Loop2010AB.N4_Pay_AddressCity_State_ZIPCode.AdditionalPatientInformationContactStateCode_02 = "FL";
loop2000A.AllNM1.Loop2010AB.N4_Pay_AddressCity_State_ZIPCode.AdditionalPatientInformationContactPostalZoneorZIPCode_03 = "33111";
// End 2010AB Loop PAY-TO PROVIDER
// Repeating 2000B Loops
loop2000A.Loop2000B = new List <Loop_2000B_837P>();
// Begin 2000B Loop SUBSCRIBER Hierarchy
var loop2000B = new Loop_2000B_837P();
// Hierarchical Number 2
loop2000B.HL_SubscriberHierarchicalLevel = new HL_SubscriberHierarchicalLevel();
loop2000B.HL_SubscriberHierarchicalLevel.HierarchicalIDNumber_01 = "2";
loop2000B.HL_SubscriberHierarchicalLevel.HierarchicalParentIDNumber_02 = "1";
loop2000B.HL_SubscriberHierarchicalLevel.HierarchicalLevelCode_03 = "22";
loop2000B.HL_SubscriberHierarchicalLevel.HierarchicalChildCode_04 = "1";
// SUBSCRIBER GROUP #: 2222-SJ
loop2000B.SBR_SubscriberInformation = new SBR_SubscriberInformation();
loop2000B.SBR_SubscriberInformation.PayerResponsibilitySequenceNumberCode_01 = "P";
loop2000B.SBR_SubscriberInformation.InsuredGrouporPolicyNumber_03 = "2222-SJ";
loop2000B.SBR_SubscriberInformation.ClaimFilingIndicatorCode_09 = "CI";
// Occurrence of NM1 Loops in any order
loop2000B.AllNM1 = new All_NM1_837P_2();
// Begin 2010BA Loop SUBSCRIBER
loop2000B.AllNM1.Loop2010BA = new Loop_2010BA_837P();
// SUBSCRIBER name is Jane Smith
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName = new NM1_InsuredName();
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.EntityIdentifierCode_01 = "IL";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.EntityTypeQualifier_02 = "1";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactLastorOrganizationName_03 = "SMITH";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactFirstName_04 = "JANE";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.IdentificationCodeQualifier_08 = "MI";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactIdentifier_09 = "JS00111223333";
// SUBSCRIBER SEX: F and DOB: 05 / 01 / 43
loop2000B.AllNM1.Loop2010BA.DMG_SubscriberDemographicInformation = new DMG_DependentDemographicInformation();
loop2000B.AllNM1.Loop2010BA.DMG_SubscriberDemographicInformation.DateTimePeriodFormatQualifier_01 = "D8";
loop2000B.AllNM1.Loop2010BA.DMG_SubscriberDemographicInformation.DependentBirthDate_02 = "19430501";
loop2000B.AllNM1.Loop2010BA.DMG_SubscriberDemographicInformation.DependentGenderCode_03 = "F";
// End 2010BA Loop SUBSCRIBER
// Begin 2010BB Loop PAYER
loop2000B.AllNM1.Loop2010BB = new Loop_2010BB_837P();
// Payer name is Key Insurance Company with PAYER ID: 999996666
loop2000B.AllNM1.Loop2010BB.NM1_PayerName = new NM1_CorrectedPriorityPayerName();
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.EntityIdentifierCode_01 = "PR";
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.EntityTypeQualifier_02 = "2";
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.ResponseContactLastorOrganizationName_03 = "KEY INSURANCE COMPANY";
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.IdentificationCodeQualifier_08 = "PI";
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.ResponseContactIdentifier_09 = "999996666";
// Occurrence of REF in any order
loop2000B.AllNM1.Loop2010BB.AllREF = new All_REF_837P_5();
// Repeating REF
loop2000B.AllNM1.Loop2010BB.AllREF.REF_BillingProviderSecondaryIdentification = new List <REF_BillingProviderSecondaryIdentification>();
// KEY INSURANCE COMPANY PROVIDER ID #: KA6663
var refLoop2000B = new REF_BillingProviderSecondaryIdentification();
refLoop2000B.ReferenceIdentificationQualifier_01 = "G2";
refLoop2000B.MemberGrouporPolicyNumber_02 = "KA6663";
loop2000B.AllNM1.Loop2010BB.AllREF.REF_BillingProviderSecondaryIdentification.Add(refLoop2000B);
// End 2010BB Loop PAYER
// Repeating 2000C Loops
loop2000B.Loop2000C = new List <Loop_2000C_837P>();
// Begin 2000C Loop PATIENT Hierarchy
var loop2000C = new Loop_2000C_837P();
// Hierarchical Number 3
loop2000C.HL_PatientHierarchicalLevel = new HL_DependentLevel();
loop2000C.HL_PatientHierarchicalLevel.HierarchicalIDNumber_01 = "3";
loop2000C.HL_PatientHierarchicalLevel.HierarchicalParentIDNumber_02 = "2";
loop2000C.HL_PatientHierarchicalLevel.HierarchicalLevelCode_03 = "23";
loop2000C.HL_PatientHierarchicalLevel.HierarchicalChildCode_04 = "0";
loop2000C.PAT_PatientInformation = new PAT_PatientInformation();
loop2000C.PAT_PatientInformation.IndividualRelationshipCode_01 = "19";
// Begin 2010CA Loop PATIENT
loop2000C.Loop2010CA = new Loop_2010CA_837P();
// PATIENT name is Ted Smith
loop2000C.Loop2010CA.NM1_PatientName = new NM1_DependentName_2();
loop2000C.Loop2010CA.NM1_PatientName.EntityIdentifierCode_01 = "QC";
loop2000C.Loop2010CA.NM1_PatientName.EntityTypeQualifier_02 = "1";
loop2000C.Loop2010CA.NM1_PatientName.ResponseContactLastorOrganizationName_03 = "SMITH";
loop2000C.Loop2010CA.NM1_PatientName.ResponseContactFirstName_04 = "TED";
// PATIENT ADDRESS: 236 N. Main St.
loop2000C.Loop2010CA.N3_PatientAddress = new N3_AdditionalPatientInformationContactAddress();
loop2000C.Loop2010CA.N3_PatientAddress.ResponseContactAddressLine_01 = "236 N MAIN ST";
// PATIENT LOCATION: Miami, Fl, 33413
loop2000C.Loop2010CA.N4_PatientCity_State_ZIPCode = new N4_AdditionalPatientInformationContactCity();
loop2000C.Loop2010CA.N4_PatientCity_State_ZIPCode.AdditionalPatientInformationContactCityName_01 = "MIAMI";
loop2000C.Loop2010CA.N4_PatientCity_State_ZIPCode.AdditionalPatientInformationContactStateCode_02 = "FL";
loop2000C.Loop2010CA.N4_PatientCity_State_ZIPCode.AdditionalPatientInformationContactPostalZoneorZIPCode_03 = "33413";
// PATIENT SEX: M and DOB: 05 / 01 / 73
loop2000C.Loop2010CA.DMG_PatientDemographicInformation = new DMG_DependentDemographicInformation();
loop2000C.Loop2010CA.DMG_PatientDemographicInformation.DateTimePeriodFormatQualifier_01 = "D8";
loop2000C.Loop2010CA.DMG_PatientDemographicInformation.DependentBirthDate_02 = "19730501";
loop2000C.Loop2010CA.DMG_PatientDemographicInformation.DependentGenderCode_03 = "M";
// End 2010CA Loop PATIENT
// Repeating 2300 Loops
loop2000C.Loop2300 = new List <Loop_2300_837P>();
// Begin 2300 Loop CLAIM
var loop2300 = new Loop_2300_837P();
// PATIENT ACCOUNT NUMBER: 2-646-3774
loop2300.CLM_ClaimInformation = new CLM_ClaimInformation();
loop2300.CLM_ClaimInformation.PatientControlNumber_01 = "26463774";
loop2300.CLM_ClaimInformation.TotalClaimChargeAmount_02 = "100";
loop2300.CLM_ClaimInformation.HealthCareServiceLocationInformation_05 = new C023_HealthCareServiceLocationInformation();
loop2300.CLM_ClaimInformation.HealthCareServiceLocationInformation_05.FacilityTypeCode_01 = "11";
loop2300.CLM_ClaimInformation.HealthCareServiceLocationInformation_05.FacilityCodeQualifier_02 = "B";
loop2300.CLM_ClaimInformation.HealthCareServiceLocationInformation_05.ClaimFrequencyTypeCode_03 = "1";
loop2300.CLM_ClaimInformation.ProviderorSupplierSignatureIndicator_06 = "Y";
loop2300.CLM_ClaimInformation.AssignmentorPlanParticipationCode_07 = "A";
loop2300.CLM_ClaimInformation.BenefitsAssignmentCertificationIndicator_08 = "Y";
loop2300.CLM_ClaimInformation.ReleaseofInformationCode_09 = "I";
// Occurrence of REF in any order
loop2300.AllREF = new All_REF_837P_6();
// ELECTRONIC ROUTE: Billing provider (sender), to VAN to Key Insurance Company (receiver). VAN claim identification number = 17312345600006351.
loop2300.AllREF.REF_ClaimIdentifierForTransmissionIntermediaries = new REF_ClaimIdentificationNumberForClearinghousesandOtherTransmissionIntermediaries();
loop2300.AllREF.REF_ClaimIdentifierForTransmissionIntermediaries.ReferenceIdentificationQualifier_01 = "D9";
loop2300.AllREF.REF_ClaimIdentifierForTransmissionIntermediaries.MemberGrouporPolicyNumber_02 = "17312345600006351";
// Occurrence of HI in any order
loop2300.AllHI = new All_HI_837P();
// CASE: Patient has sore throat.
loop2300.AllHI.HI_HealthCareDiagnosisCode = new HI_DependentHealthCareDiagnosisCode();
loop2300.AllHI.HI_HealthCareDiagnosisCode.HealthCareCodeInformation_01 = new C022_HealthCareCodeInformation();
loop2300.AllHI.HI_HealthCareDiagnosisCode.HealthCareCodeInformation_01.CodeListQualifierCode_01 = "BK";
loop2300.AllHI.HI_HealthCareDiagnosisCode.HealthCareCodeInformation_01.IndustryCode_02 = "0340";
loop2300.AllHI.HI_HealthCareDiagnosisCode.HealthCareCodeInformation_02 = new C022_HealthCareCodeInformation();
loop2300.AllHI.HI_HealthCareDiagnosisCode.HealthCareCodeInformation_02.CodeListQualifierCode_01 = "BF";
loop2300.AllHI.HI_HealthCareDiagnosisCode.HealthCareCodeInformation_02.IndustryCode_02 = "V7389";
// Repeating 2400 Loops
loop2300.Loop2400 = new List <Loop_2400_837P>();
// Begin 2400 Loop SERVICE LINE 1
var loop24001 = new Loop_2400_837P();
loop24001.LX_ServiceLineNumber = new LX_HeaderNumber();
loop24001.LX_ServiceLineNumber.AssignedNumber_01 = "1";
// SERVICES: Office visit, intermediate service, established patient, throat culture.
// CHARGES: Office first visit = $40.00
loop24001.SV1_ProfessionalService = new SV1_ProfessionalService();
loop24001.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01 = new C003_CompositeMedicalProcedureIdentifier();
loop24001.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01.ProductorServiceIDQualifier_01 = "HC";
loop24001.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01.ProcedureCode_02 = "99213";
loop24001.SV1_ProfessionalService.LineItemChargeAmount_02 = "40";
loop24001.SV1_ProfessionalService.UnitorBasisforMeasurementCode_03 = "UN";
loop24001.SV1_ProfessionalService.ServiceUnitCount_04 = "1";
loop24001.SV1_ProfessionalService.CompositeDiagnosisCodePointer_07 = new C004_CompositeDiagnosisCodePointer();
loop24001.SV1_ProfessionalService.CompositeDiagnosisCodePointer_07.DiagnosisCodePointer_01 = "1";
// Occurrence of DTP in any order
loop24001.AllDTP = new All_DTP_837P();
// INITIAL VISIT: DOS=10/03/06. POS=Office
loop24001.AllDTP.DTP_Date_ServiceDate = new DTP_ClaimLevelServiceDate();
loop24001.AllDTP.DTP_Date_ServiceDate.DateTimeQualifier_01 = "472";
loop24001.AllDTP.DTP_Date_ServiceDate.DateTimePeriodFormatQualifier_02 = "D8";
loop24001.AllDTP.DTP_Date_ServiceDate.AccidentDate_03 = "20061003";
// End 2400 Loop SERVICE LINE 1
loop2300.Loop2400.Add(loop24001);
// Begin 2400 Loop SERVICE LINE 2
var loop24002 = new Loop_2400_837P();
loop24002.LX_ServiceLineNumber = new LX_HeaderNumber();
loop24002.LX_ServiceLineNumber.AssignedNumber_01 = "2";
// SERVICES: Office visit, intermediate service, established patient, throat culture.
// CHARGES: Lab test for strep = $15.00
loop24002.SV1_ProfessionalService = new SV1_ProfessionalService();
loop24002.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01 = new C003_CompositeMedicalProcedureIdentifier();
loop24002.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01.ProductorServiceIDQualifier_01 = "HC";
loop24002.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01.ProcedureCode_02 = "87070";
loop24002.SV1_ProfessionalService.LineItemChargeAmount_02 = "15";
loop24002.SV1_ProfessionalService.UnitorBasisforMeasurementCode_03 = "UN";
loop24002.SV1_ProfessionalService.ServiceUnitCount_04 = "1";
loop24002.SV1_ProfessionalService.CompositeDiagnosisCodePointer_07 = new C004_CompositeDiagnosisCodePointer();
loop24002.SV1_ProfessionalService.CompositeDiagnosisCodePointer_07.DiagnosisCodePointer_01 = "1";
// Occurrence of DTP in any order
loop24002.AllDTP = new All_DTP_837P();
// INITIAL VISIT: DOS=10/03/06. POS=Office
loop24002.AllDTP.DTP_Date_ServiceDate = new DTP_ClaimLevelServiceDate();
loop24002.AllDTP.DTP_Date_ServiceDate.DateTimeQualifier_01 = "472";
loop24002.AllDTP.DTP_Date_ServiceDate.DateTimePeriodFormatQualifier_02 = "D8";
loop24002.AllDTP.DTP_Date_ServiceDate.AccidentDate_03 = "20061003";
// End 2400 Loop SERVICE LINE 2
loop2300.Loop2400.Add(loop24002);
// Begin 2400 Loop SERVICE LINE 3
var loop24003 = new Loop_2400_837P();
loop24003.LX_ServiceLineNumber = new LX_HeaderNumber();
loop24003.LX_ServiceLineNumber.AssignedNumber_01 = "3";
// SERVICES: Office visit, intermediate service, established patient, mono screening.
// CHARGES: Follow-up visit = $35.00
loop24003.SV1_ProfessionalService = new SV1_ProfessionalService();
loop24003.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01 = new C003_CompositeMedicalProcedureIdentifier();
loop24003.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01.ProductorServiceIDQualifier_01 = "HC";
loop24003.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01.ProcedureCode_02 = "99214";
loop24003.SV1_ProfessionalService.LineItemChargeAmount_02 = "35";
loop24003.SV1_ProfessionalService.UnitorBasisforMeasurementCode_03 = "UN";
loop24003.SV1_ProfessionalService.ServiceUnitCount_04 = "1";
loop24003.SV1_ProfessionalService.CompositeDiagnosisCodePointer_07 = new C004_CompositeDiagnosisCodePointer();
loop24003.SV1_ProfessionalService.CompositeDiagnosisCodePointer_07.DiagnosisCodePointer_01 = "2";
// Occurrence of DTP in any order
loop24003.AllDTP = new All_DTP_837P();
// FOLLOW-UP VISIT: DOS=10/10/06 POS=Office
loop24003.AllDTP.DTP_Date_ServiceDate = new DTP_ClaimLevelServiceDate();
loop24003.AllDTP.DTP_Date_ServiceDate.DateTimeQualifier_01 = "472";
loop24003.AllDTP.DTP_Date_ServiceDate.DateTimePeriodFormatQualifier_02 = "D8";
loop24003.AllDTP.DTP_Date_ServiceDate.AccidentDate_03 = "20061010";
// End 2400 Loop SERVICE LINE 3
loop2300.Loop2400.Add(loop24003);
// Begin 2400 Loop SERVICE LINE 4
var loop24004 = new Loop_2400_837P();
loop24004.LX_ServiceLineNumber = new LX_HeaderNumber();
loop24004.LX_ServiceLineNumber.AssignedNumber_01 = "4";
// SERVICES: Office visit, intermediate service, established patient, mono screening.
// CHARGES: Lab test for mono = $10.00
loop24004.SV1_ProfessionalService = new SV1_ProfessionalService();
loop24004.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01 = new C003_CompositeMedicalProcedureIdentifier();
loop24004.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01.ProductorServiceIDQualifier_01 = "HC";
loop24004.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01.ProcedureCode_02 = "86663";
loop24004.SV1_ProfessionalService.LineItemChargeAmount_02 = "10";
loop24004.SV1_ProfessionalService.UnitorBasisforMeasurementCode_03 = "UN";
loop24004.SV1_ProfessionalService.ServiceUnitCount_04 = "1";
loop24004.SV1_ProfessionalService.CompositeDiagnosisCodePointer_07 = new C004_CompositeDiagnosisCodePointer();
loop24004.SV1_ProfessionalService.CompositeDiagnosisCodePointer_07.DiagnosisCodePointer_01 = "2";
// Occurrence of DTP in any order
loop24004.AllDTP = new All_DTP_837P();
// FOLLOW-UP VISIT: DOS=10/10/06 POS=Office
loop24004.AllDTP.DTP_Date_ServiceDate = new DTP_ClaimLevelServiceDate();
loop24004.AllDTP.DTP_Date_ServiceDate.DateTimeQualifier_01 = "472";
loop24004.AllDTP.DTP_Date_ServiceDate.DateTimePeriodFormatQualifier_02 = "D8";
loop24004.AllDTP.DTP_Date_ServiceDate.AccidentDate_03 = "20061010";
// End 2400 Loop SERVICE LINE 4
loop2300.Loop2400.Add(loop24004);
// End 2300 Loop CLAIM
loop2000C.Loop2300.Add(loop2300);
// End 2000C Loop PATIENT Hierarchy
loop2000B.Loop2000C.Add(loop2000C);
// End 2000B Loop SUBSCRIBER Hierarchy
loop2000A.Loop2000B.Add(loop2000B);
// End 2000A Loop BILLING PROVIDER Hierarchy
result.Loop2000A.Add(loop2000A);
return(result);
}
/// <summary>
/// Build dental claim.
/// Original from http://www.x12.org/examples/005010X224/commercial-health-insurance/
/// The patient is a different person than the subscriber. The payer is a commercial health insurance company.
/// Scenario:
/// SUBSCRIBER: Jane Smith
/// KEY INSURANCE COMPANY ID #: SSN
/// SSN: 111-22-3333
/// PATIENT: Ted Smith
/// PATIENT ADDRESS: 236 N.Main St., Miami, Fl, 33413
/// SEX: M
/// DOB: 05/01/1992
/// PATIENT RELATIONSHIP: Child
/// DESTINATION PAYER: Insurance Company XYZ
/// RECEIVER: Insurance Company XYZ
/// ETIN#: 66783JJT
/// SUBMITTER: Premier Billing Service
/// ETIN#: TGJ23
/// BILLING PROVIDER: Dental Associates
/// NPI: 1234567890
/// TIN: 587654321
/// ADDRESS: 234 Seaway St., Miami, FL, 33111
/// RENDERING PROVIDER: Dr.Ben Kildare
/// NPI: 9876543210
/// PATIENT ACCOUNT NUMBER: 2-640-3774
/// DOS: 20061029
/// POS= Office
/// SERVICES RENDERED: Two surface amalgam on tooth #12 (mesial and occlusal surfaces) and prophy.
/// CHARGES: amalgam = $100.00, prophy = $50.00.
/// ELECTRONIC ROUTE: VAN submits claim on behalf of billing provider (submitter) to Insurance Company XYZ (receiver).
/// VAN CLAIM IDENTIFICATION NUMBER: 17312345600006351.
/// </summary>
static TS837D BuildDentalClaim(string controlNumber)
{
var result = new TS837D();
// ST TRANSACTION SET HEADER
result.ST = new ST();
result.ST.TransactionSetIdentifierCode_01 = "837";
result.ST.TransactionSetControlNumber_02 = controlNumber.PadLeft(9, '0');
result.ST.ImplementationConventionPreference_03 = "005010X224A2";
// BHT TRANSACTION SET HIERARCHY AND CONTROL INFORMATION
result.BHT_BeginningofHierarchicalTransaction = new BHT_BeginningofHierarchicalTransaction_7();
result.BHT_BeginningofHierarchicalTransaction.HierarchicalStructureCode_01 = "0019";
result.BHT_BeginningofHierarchicalTransaction.TransactionSetPurposeCode_02 = "00";
result.BHT_BeginningofHierarchicalTransaction.SubmitterTransactionIdentifier_03 = "0123";
result.BHT_BeginningofHierarchicalTransaction.TransactionSetCreationDate_04 = "20061123";
result.BHT_BeginningofHierarchicalTransaction.TransactionSetCreationTime_05 = "1023";
result.BHT_BeginningofHierarchicalTransaction.TransactionTypeCode_06 = "CH";
// Occurrence of NM1 Loops in any order
result.AllNM1 = new All_NM1_837D_6();
// Begin 1000A Loop SUBMITTER NAME
result.AllNM1.Loop1000A = new Loop_1000A_837D();
// NM1 SUBMITTER
result.AllNM1.Loop1000A.NM1_SubmitterName = new NM1_InformationReceiverName_2();
result.AllNM1.Loop1000A.NM1_SubmitterName.EntityIdentifierCode_01 = "41";
result.AllNM1.Loop1000A.NM1_SubmitterName.EntityTypeQualifier_02 = "2";
result.AllNM1.Loop1000A.NM1_SubmitterName.ResponseContactLastorOrganizationName_03 = "PREMIER BILLING SERVICE";
result.AllNM1.Loop1000A.NM1_SubmitterName.IdentificationCodeQualifier_08 = "46";
result.AllNM1.Loop1000A.NM1_SubmitterName.ResponseContactIdentifier_09 = "TGJ23";
// Repeating PER Patient information
result.AllNM1.Loop1000A.PER_SubmitterEDIContactInformation = new List <PER_AdditionalPatientInformationContactInformation>();
// PER SUBMITTER EDI CONTACT INFORMATION
var per1 = new PER_AdditionalPatientInformationContactInformation();
per1.ContactFunctionCode_01 = "IC";
per1.ResponseContactName_02 = "JERRY";
per1.CommunicationNumberQualifier_03 = "TE";
per1.ResponseContactCommunicationNumber_04 = "7176149999";
result.AllNM1.Loop1000A.PER_SubmitterEDIContactInformation.Add(per1);
// End 1000A Loop
// Begin 1000B Loop RECEIVER NAME
result.AllNM1.Loop1000B = new Loop_1000B_837D();
// NM1 RECEIVER
result.AllNM1.Loop1000B.NM1_ReceiverName = new NM1_ReceiverName();
result.AllNM1.Loop1000B.NM1_ReceiverName.EntityIdentifierCode_01 = "40";
result.AllNM1.Loop1000B.NM1_ReceiverName.EntityTypeQualifier_02 = "2";
result.AllNM1.Loop1000B.NM1_ReceiverName.ResponseContactLastorOrganizationName_03 = "INSURANCE COMPANY XYZ";
result.AllNM1.Loop1000B.NM1_ReceiverName.IdentificationCodeQualifier_08 = "46";
result.AllNM1.Loop1000B.NM1_ReceiverName.ResponseContactIdentifier_09 = "66783JJT";
// End 1000B Loop
// Repeating 2000A Loops
result.Loop2000A = new List <Loop_2000A_837D>();
// Begin 2000A Loop BILLING PROVIDER
var loop2000A = new Loop_2000A_837D();
// HIERARCHAL LEVEL 1
loop2000A.HL_BillingProviderHierarchicalLevel = new HL_BillingProviderHierarchicalLevel();
loop2000A.HL_BillingProviderHierarchicalLevel.HierarchicalIDNumber_01 = "1";
loop2000A.HL_BillingProviderHierarchicalLevel.HierarchicalLevelCode_03 = "20";
loop2000A.HL_BillingProviderHierarchicalLevel.HierarchicalChildCode_04 = "1";
// Occurrence of NM1 Loops in any order
loop2000A.AllNM1 = new All_NM1_837D();
// Begin 2010AA Loop BILLING PROVIDER NAME
loop2000A.AllNM1.Loop2010AA = new Loop_2010AA_837D();
// NM1 BILLING PROVIDER NAME
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName = new NM1_BillingProviderName();
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.EntityIdentifierCode_01 = "85";
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.EntityTypeQualifier_02 = "2";
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.ResponseContactLastorOrganizationName_03 = "DENTAL ASSOCIATES";
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.IdentificationCodeQualifier_08 = "XX";
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.ResponseContactIdentifier_09 = "1234567890";
// N3 BILLING PROVIDER ADDRESS
loop2000A.AllNM1.Loop2010AA.N3_BillingProviderAddress = new N3_AdditionalPatientInformationContactAddress();
loop2000A.AllNM1.Loop2010AA.N3_BillingProviderAddress.ResponseContactAddressLine_01 = "234 SEAWAY ST";
// N4 BILLING PROVIDER LOCATION
loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode = new N4_AdditionalPatientInformationContactCity();
loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode.AdditionalPatientInformationContactCityName_01 = "MIAMI";
loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode.AdditionalPatientInformationContactStateCode_02 = "FL";
loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode.AdditionalPatientInformationContactPostalZoneorZIPCode_03 = "33111";
// Occurrence of REF Segments in any order
loop2000A.AllNM1.Loop2010AA.AllREF = new All_REF_837D_8();
// REF BILLING PROVIDER'S TAX IDENTIFICATION
loop2000A.AllNM1.Loop2010AA.AllREF.REF_BillingProviderTaxIdentification = new REF_BillingProviderTaxIdentification();
loop2000A.AllNM1.Loop2010AA.AllREF.REF_BillingProviderTaxIdentification.ReferenceIdentificationQualifier_01 = "EI";
loop2000A.AllNM1.Loop2010AA.AllREF.REF_BillingProviderTaxIdentification.MemberGrouporPolicyNumber_02 = "587654321";
// Repeating PER billing provider contact information
loop2000A.AllNM1.Loop2010AA.PER_BillingProviderContactInformation = new List <PER_AdditionalPatientInformationContactInformation>();
// End 2010AA Loop
// Repeating 2000B Loops
loop2000A.Loop2000B = new List <Loop_2000B_837D>();
// Begin 2000B Loop SUBSCRIBER HL LOOP
var loop2000B = new Loop_2000B_837D();
// HIERARCHAL LEVEL 2
loop2000B.HL_SubscriberHierarchicalLevel = new HL_SubscriberHierarchicalLevel();
loop2000B.HL_SubscriberHierarchicalLevel.HierarchicalIDNumber_01 = "2";
loop2000B.HL_SubscriberHierarchicalLevel.HierarchicalParentIDNumber_02 = "1";
loop2000B.HL_SubscriberHierarchicalLevel.HierarchicalLevelCode_03 = "22";
loop2000B.HL_SubscriberHierarchicalLevel.HierarchicalChildCode_04 = "1";
// SBR SUBSCRIBER INFORMATION
loop2000B.SBR_SubscriberInformation = new SBR_SubscriberInformation();
loop2000B.SBR_SubscriberInformation.PayerResponsibilitySequenceNumberCode_01 = "P";
loop2000B.SBR_SubscriberInformation.ClaimFilingIndicatorCode_09 = "CI";
// Occurrence of NM1 Loops in any order
loop2000B.AllNM1 = new All_NM1_837D_2();
// Begin 2010BA Loop SUBSCRIBER NAME LOOP
loop2000B.AllNM1.Loop2010BA = new Loop_2010BA_837D();
// NM1 SUBSCRIBER'S NAME
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName = new NM1_InsuredName();
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.EntityIdentifierCode_01 = "IL";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.EntityTypeQualifier_02 = "1";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactLastorOrganizationName_03 = "SMITH";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactFirstName_04 = "JANE";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.IdentificationCodeQualifier_08 = "MI";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactIdentifier_09 = "111223333";
// End 2010BA Loop
// Begin 2010BB Loop PAYER NAME LOOP
loop2000B.AllNM1.Loop2010BB = new Loop_2010BB_837D();
// NM1 PAYER'S NAME
loop2000B.AllNM1.Loop2010BB.NM1_PayerName = new NM1_CorrectedPriorityPayerName();
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.EntityIdentifierCode_01 = "PR";
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.EntityTypeQualifier_02 = "2";
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.ResponseContactLastorOrganizationName_03 = "INSURANCE COMPANY XYZ";
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.IdentificationCodeQualifier_08 = "PI";
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.ResponseContactIdentifier_09 = "66783JJT";
// End 2010BB Loop
// Repeating 2000C Loops
loop2000B.Loop2000C = new List <Loop_2000C_837D>();
// Begin 2000C Loop PATIENT'S HL LOOP
var loop2000C = new Loop_2000C_837D();
// HIERARCHAL LEVEL 3
loop2000C.HL_PatientHierarchicalLevel = new HL_DependentLevel();
loop2000C.HL_PatientHierarchicalLevel.HierarchicalIDNumber_01 = "3";
loop2000C.HL_PatientHierarchicalLevel.HierarchicalParentIDNumber_02 = "2";
loop2000C.HL_PatientHierarchicalLevel.HierarchicalLevelCode_03 = "23";
loop2000C.HL_PatientHierarchicalLevel.HierarchicalChildCode_04 = "0";
// PAT PATIENT INFORMATION
loop2000C.PAT_PatientInformation = new PAT_PatientInformation();
loop2000C.PAT_PatientInformation.IndividualRelationshipCode_01 = "19";
// Begin 2010CA Loop PATIENT
loop2000C.Loop2010CA = new Loop_2010CA_837D();
// NM1 PATIENT'S NAME
loop2000C.Loop2010CA.NM1_PatientName = new NM1_DependentName_2();
loop2000C.Loop2010CA.NM1_PatientName.EntityIdentifierCode_01 = "QC";
loop2000C.Loop2010CA.NM1_PatientName.EntityTypeQualifier_02 = "1";
loop2000C.Loop2010CA.NM1_PatientName.ResponseContactLastorOrganizationName_03 = "SMITH";
loop2000C.Loop2010CA.NM1_PatientName.ResponseContactFirstName_04 = "TED";
// N3 PATIENT'S ADDRESS
loop2000C.Loop2010CA.N3_PatientAddress = new N3_AdditionalPatientInformationContactAddress();
loop2000C.Loop2010CA.N3_PatientAddress.ResponseContactAddressLine_01 = "236 N MAIN ST";
// N4 PATIENT'S CITY
loop2000C.Loop2010CA.N4_PatientCity_State_ZIPCode = new N4_AdditionalPatientInformationContactCity();
loop2000C.Loop2010CA.N4_PatientCity_State_ZIPCode.AdditionalPatientInformationContactCityName_01 = "MIAMI";
loop2000C.Loop2010CA.N4_PatientCity_State_ZIPCode.AdditionalPatientInformationContactStateCode_02 = "FL";
loop2000C.Loop2010CA.N4_PatientCity_State_ZIPCode.AdditionalPatientInformationContactPostalZoneorZIPCode_03 = "33413";
// DMG PATIENT DEMOGRAPHIC INFORMATION
loop2000C.Loop2010CA.DMG_PatientDemographicInformation = new DMG_DependentDemographicInformation();
loop2000C.Loop2010CA.DMG_PatientDemographicInformation.DateTimePeriodFormatQualifier_01 = "D8";
loop2000C.Loop2010CA.DMG_PatientDemographicInformation.DependentBirthDate_02 = "19920501";
loop2000C.Loop2010CA.DMG_PatientDemographicInformation.DependentGenderCode_03 = "M";
// End 2010CA Loop
// Repeating 2300 Loops
loop2000C.Loop2300 = new List <Loop_2300_837D>();
// Begin 2300 Loop CLAIM
var loop2300 = new Loop_2300_837D();
// CLM HEALTH CLAIM INFORMATION
loop2300.CLM_ClaimInformation = new CLM_ClaimInformation();
loop2300.CLM_ClaimInformation.PatientControlNumber_01 = "26403774";
loop2300.CLM_ClaimInformation.TotalClaimChargeAmount_02 = "150";
loop2300.CLM_ClaimInformation.HealthCareServiceLocationInformation_05 = new C023_HealthCareServiceLocationInformation();
loop2300.CLM_ClaimInformation.HealthCareServiceLocationInformation_05.FacilityTypeCode_01 = "11";
loop2300.CLM_ClaimInformation.HealthCareServiceLocationInformation_05.FacilityCodeQualifier_02 = "B";
loop2300.CLM_ClaimInformation.HealthCareServiceLocationInformation_05.ClaimFrequencyTypeCode_03 = "1";
loop2300.CLM_ClaimInformation.ProviderorSupplierSignatureIndicator_06 = "Y";
loop2300.CLM_ClaimInformation.AssignmentorPlanParticipationCode_07 = "A";
loop2300.CLM_ClaimInformation.BenefitsAssignmentCertificationIndicator_08 = "Y";
loop2300.CLM_ClaimInformation.ReleaseofInformationCode_09 = "I";
// Occurrence of DTP Segments in any order
loop2300.AllDTP = new All_DTP_837D_2();
// DTP DATE - SERVICE DATE
loop2300.AllDTP.DTP_Date_ServiceDate = new DTP_ClaimLevelServiceDate();
loop2300.AllDTP.DTP_Date_ServiceDate.DateTimeQualifier_01 = "472";
loop2300.AllDTP.DTP_Date_ServiceDate.DateTimePeriodFormatQualifier_02 = "D8";
loop2300.AllDTP.DTP_Date_ServiceDate.AccidentDate_03 = "20061029";
// Occurrence of REF Segments in any order
loop2300.AllREF = new All_REF_837D_6();
// REF VAN CLAIM NUMBER
loop2300.AllREF.REF_ClaimIdentifierForTransmissionIntermediaries = new REF_ClaimIdentificationNumberForClearinghousesandOtherTransmissionIntermediaries();
loop2300.AllREF.REF_ClaimIdentifierForTransmissionIntermediaries.ReferenceIdentificationQualifier_01 = "D9";
loop2300.AllREF.REF_ClaimIdentifierForTransmissionIntermediaries.MemberGrouporPolicyNumber_02 = "17312345600006351";
// Occurrence of NM1 Loops in any order
loop2300.AllNM1 = new All_NM1_837D_3();
// Begin 2310B Loop RENDERING PROVIDER
loop2300.AllNM1.Loop2310B = new Loop_2310B_837D();
// NM1 RENDERING PROVIDER’S NAME
loop2300.AllNM1.Loop2310B.NM1_RenderingProviderName = new NM1_OtherPayerRenderingProvider_2();
loop2300.AllNM1.Loop2310B.NM1_RenderingProviderName.EntityIdentifierCode_01 = "82";
loop2300.AllNM1.Loop2310B.NM1_RenderingProviderName.EntityTypeQualifier_02 = "1";
loop2300.AllNM1.Loop2310B.NM1_RenderingProviderName.ResponseContactLastorOrganizationName_03 = "KILDARE";
loop2300.AllNM1.Loop2310B.NM1_RenderingProviderName.ResponseContactFirstName_04 = "BEN";
loop2300.AllNM1.Loop2310B.NM1_RenderingProviderName.IdentificationCodeQualifier_08 = "XX";
loop2300.AllNM1.Loop2310B.NM1_RenderingProviderName.ResponseContactIdentifier_09 = "9876543210";
loop2300.AllNM1.Loop2310B.PRV_RenderingProviderSpecialtyInformation = new PRV_RenderingProviderSpecialtyInformation();
loop2300.AllNM1.Loop2310B.PRV_RenderingProviderSpecialtyInformation.ProviderCode_01 = "PE";
loop2300.AllNM1.Loop2310B.PRV_RenderingProviderSpecialtyInformation.ReferenceIdentificationQualifier_02 = "PXC";
loop2300.AllNM1.Loop2310B.PRV_RenderingProviderSpecialtyInformation.ProviderTaxonomyCode_03 = "1223G0001X";
// End 2310B Loop
// Repeating 2400 Loops
loop2300.Loop2400 = new List <Loop_2400_837D>();
// Begin 2400 Loop 1 SERVICE LINE
var loop24001 = new Loop_2400_837D();
// LX SERVICE LINE NUMBER
loop24001.LX_ServiceLineNumber = new LX_HeaderNumber();
loop24001.LX_ServiceLineNumber.AssignedNumber_01 = "1";
// SV3 DENTAL SERVICE
loop24001.SV3_DentalService = new SV3_DentalService();
loop24001.SV3_DentalService.CompositeMedicalProcedureIdentifier_01 = new C003_CompositeMedicalProcedureIdentifier();
loop24001.SV3_DentalService.CompositeMedicalProcedureIdentifier_01.ProductorServiceIDQualifier_01 = "AD";
loop24001.SV3_DentalService.CompositeMedicalProcedureIdentifier_01.ProcedureCode_02 = "D2150";
loop24001.SV3_DentalService.LineItemChargeAmount_02 = "100";
loop24001.SV3_DentalService.ProcedureCount_06 = "1";
// Repeating TOO
loop24001.TOO_ToothInformation = new List <TOO_ToothInformation>();
// TOO TOOTH NUMBER/SURFACES
var too = new TOO_ToothInformation();
too.CodeListQualifierCode_01 = "JP";
too.ToothCode_02 = "12";
too.ToothSurface_03 = new C005_ToothSurface();
too.ToothSurface_03.ToothSurfaceCode_01 = "M";
too.ToothSurface_03.ToothSurfaceCode_02 = "O";
loop24001.TOO_ToothInformation.Add(too);
// End 2400 Loop 1
loop2300.Loop2400.Add(loop24001);
// Begin 2400 Loop 2 SERVICE LINE
var loop24002 = new Loop_2400_837D();
// LX SERVICE LINE NUMBER
loop24002.LX_ServiceLineNumber = new LX_HeaderNumber();
loop24002.LX_ServiceLineNumber.AssignedNumber_01 = "2";
// SV3 DENTAL SERVICE
loop24002.SV3_DentalService = new SV3_DentalService();
loop24002.SV3_DentalService.CompositeMedicalProcedureIdentifier_01 = new C003_CompositeMedicalProcedureIdentifier();
loop24002.SV3_DentalService.CompositeMedicalProcedureIdentifier_01.ProductorServiceIDQualifier_01 = "AD";
loop24002.SV3_DentalService.CompositeMedicalProcedureIdentifier_01.ProcedureCode_02 = "D1110";
loop24002.SV3_DentalService.LineItemChargeAmount_02 = "50";
loop24002.SV3_DentalService.ProcedureCount_06 = "1";
// End 2400 Loop 2
loop2300.Loop2400.Add(loop24002);
// End 2300 Loop
loop2000C.Loop2300.Add(loop2300);
// End 2000C Loop
loop2000B.Loop2000C.Add(loop2000C);
// End 2000B Loop
loop2000A.Loop2000B.Add(loop2000B);
// End 2000A Loop
result.Loop2000A.Add(loop2000A);
return(result);
}
